Post-traumatic stress disorder symptom duration and remission in relation to cardiovascular disease risk among a large cohort of women

Maladaptive health factors as potential mediators for the association between posttraumatic stress disorder and cardiovascular disease: A sex-stratified analysis in the U.S. adult population

OBJECTIVES

This study examined sex differences for health risk factors as potential mediators in the association between posttraumatic stress disorder (PTSD) and cardiovascular disease (CVD).

METHODS

Secondary data from the 2012-2013 National Epidemiological Survey on Alcohol and Related Conditions Wave 3 was used. This cross-sectional survey contains a nationally representative sample of 36,309 U.S. adults (nfemales = 20,447, Mage = 47.16, 95% CI = [46.74, 47,57]; nmales = 15,682, Mage = 45.88, 95% CI = [45.42, 46.34]). Natural effect models and logistic regression analyses were conducted to evaluate health risk factors (smoking, substance use, low physical activity, high body mass index [BMI], binge eating, and multiple health risk factors) as potential mediators for the PTSD-CVD relationship in females and males.

RESULTS

High BMI (indirect AOR = 1.05, 95% CI = [1.02, 1.07]) and substance use (indirect AOR = 0.93, 95% CI = [0.88, 0.98], p = 0.005) were potential mediators in females and males respectively. Binge eating, smoking, and low physical activity were not mediators in either sex. The number of health risk factors was also a potential mediator in females (indirect AOR = 1.12, 95% CI = [1.07, 1.19], p = <0.001) though not males (indirect AOR = 1.09, 95% CI = [1.00, 1.19], p = .059).

CONCLUSIONS

The results inform prevention strategies, such as screening for health risk factors to mitigate the adverse effect of PTSD on CVD risk. Findings also inform important directions for future longitudinal research to establish causal pathways.

Association between childhood abuse and risk of post-COVID-19 conditions: Results from three large prospective cohort studies

BACKGROUND

Significant early life adversities, such as childhood sexual and physical/emotional abuse, are associated with risk of poor health outcomes but are understudied risk factors for post-COVID-19 conditions. In this prospective study, we examined the associations between combined exposure to sexual and physical/emotional abuse during childhood with risk of post-COVID-19 conditions in adulthood. Additionally, we explored the extent to which lifestyle, health-related and psychological factors explain this association.

METHODS

We used data from three large, ongoing cohorts: Nurses' Health Study (NHS)-II, NHS3, and the Growing Up Today Study. Between April 2020 and November 2021, participants responded to periodic COVID-19 surveys. Participants were included if they responded to a questionnaire about childhood abuse, subsequently tested positive for SARS-CoV-2 infection and responded to questions about post-COVID-19 conditions. Childhood sexual abuse was measured before the COVID-19 pandemic with the Sexual Maltreatment Scale of the Parent-Child Conflict Tactics Scale, and physical/emotional abuse was measured with the Physical and Emotional Abuse Subscale of the Childhood Trauma Questionnaire. Post-COVID-19 conditions, defined as COVID-19-related symptoms lasting 4 weeks or longer (e.g., fatigue, dyspnea), were self-reported in the final COVID-19 questionnaire in November 2021. Sexual abuse and physical/emotional abuse were examined separately and jointly in relation to post-COVID-19 conditions. Data on key lifestyle (e.g., cigarette smoking), health-related (e.g., asthma, diabetes), and psychological factors (e.g., depression and anxiety) were obtained.

RESULTS

Of 2851 participants, the mean age (range) was 55.8 (22.0-75.0) years; 2789 (97.8 %) were females, and 2750 (96.5 %) were whites. We observed a dose-dependent relationship between severity of childhood abuse and post-COVID conditions (p-trend:<0.0001); participants with severe versus no childhood abuse had a 42 % higher subsequent risk of post-COVID conditions [relative risk (95 % confidence interval): 1.42 (1.25 to 1.61)]. Key lifestyle, health-related, and psychological factors mediated 25.5 % of this association. Both sexual and physical/emotional abuse, were independently associated with post-COVID conditions.

CONCLUSIONS

In this prospective study of 2851 participants, childhood abuse was significantly associated with increased risk of post-COVID conditions. Biological pathways connecting childhood abuse with subsequent risk of post-COVID conditions should be investigated.

Maternal Mental Health, COVID-19-Related Distress, and Disruptions in Lifestyle Behaviors Among Postpartum Mothers With a Previous Hypertensive Disorder of Pregnancy

BACKGROUND

Many perinatal people experienced pandemic-related distress and changes in health behaviors at the onset of the COVID-19 pandemic, but less is known about how the pandemic continued to impact their health.

OBJECTIVE

The authors of this study examined the influence of pandemic-related distress and maternal mental health on postpartum lifestyle behaviors of mothers with a previous hypertensive disorder of pregnancy.

METHODS

Between September 2021 and March 2022, 82 postpartum (19.2 ± 5.5 months) mothers with a hypertensive disorder of pregnancy completed measures of pandemic-related distress and pandemic-related disruption in lifestyle behaviors from the Coronavirus Perinatal Experiences Impact Survey. A Patient Health Questionnaire-9 score ≥ 10 and a score ≥ 3 on the Breslau scale indicated significant depressive and posttraumatic stress disorder (PTSD) symptoms, respectively.

RESULTS

Twenty-two (27.2%) and 30 (36.6%) participants had significant depressive or PTSD symptoms, respectively. In models adjusted for education, income, parity, delivery prepandemic or peripandemic, intervention group, and prepregnancy mental health history, both PTSD symptoms ( B = 0.229, P = .029) and pandemic-related distress ( B = 0.492, P < .001) associated with greater disruption in health behaviors. Depressive symptoms did not associate with greater disruption in health behaviors ( B = 0.169, P = .135).

CONCLUSION

Monitoring PTSD symptoms may be vital in supporting mothers with hypertensive disorders of pregnancy in making lifestyle changes to prevent cardiovascular disease.

Posttraumatic Stress Disorder Is Associated With Elevated Risk of Incident Stroke and Transient Ischemic Attack in Women Veterans

BACKGROUND

Posttraumatic stress disorder (PTSD) has been associated with ischemic heart disease in women veterans, but evidence for associations with other cardiovascular disorders remains limited in this population. This retrospective longitudinal cohort study evaluated the association of PTSD with incident stroke/transient ischemic attack (TIA) in women veterans.

METHODS AND RESULTS

Veterans Health Administration electronic health records were used to identify women veterans aged ≥18 years engaged with Veterans Health Administration health care from January 1, 2000 to December 31, 2019. We identified women veterans with and without PTSD without a history of stroke or TIA at start of follow-up. Propensity score matching was used to match groups on age, race or ethnicity, traditional cardiovascular risk factors, female-specific risk factors, a range of mental and physical health conditions, and number of prior health care visits. PTSD, stroke, TIA, and risk factors used in propensity score matching were based on diagnostic codes. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% CIs for associations of PTSD with an incident stroke/TIA composite. Subanalyses considered stroke and TIA separately, plus age- and race- or ethnicity-stratified analyses were carried out. The analytic sample included 208 092 women veterans (104 046 with and 104 046 without PTSD). PTSD was associated with a greater rate of developing stroke/TIA (HR, 1.33 [95% CI, 1.25-1.42], P<0.001). This elevated risk was especially pronounced in women <50 years old and in Hispanic/Latina women.

CONCLUSIONS

Findings indicate a strong association of PTSD with incident stroke/TIA in women veterans. Research is needed to determine whether addressing PTSD and its downstream consequences can offset this risk.

Psychological Health and Ischemic Heart Disease in Women: A Review of Current Evidence and Clinical Considerations across the Healthspan

PURPOSE OF REVIEW

Psychological health encompasses a constellation of negative and positive factors-i.e., psychosocial stress, depression, anxiety, trauma, loneliness and social isolation, anger and hostility, optimism, and a sense of purpose. This narrative review presents current evidence at the intersection of psychological health, risk of ischemic heart disease (IHD), and IHD-related outcomes, with an emphasis on associations in women.

RECENT FINDINGS

For women, relations between psychological health and IHD reflect important sex and gender differences in biological and psychosocial factors. Although efforts devoted to understanding psychological health and IHD risk have varied by psychological factor-scientific evidence is strongest for psychosocial stress and depression, while anxiety, trauma, and positive psychological factors warrant more investigation-less optimal psychological health is consistently associated with an earlier and greater risk of IHD morbidity and mortality in women. Still, many past prospective studies of psychological factors and IHD risk had a limited representation of women, did not include analyses by sex, or failed to account for other influential, sex-specific factors. Thus, there are multiple pathways for further, rigorous investigation into psychological health-IHD associations, mechanisms, and empirically supported psychological interventions to mitigate IHD risk among women. Given the robust evidence linking psychological health with women's risk for IHD, implementing routine, brief, psychological screening is recommended. Significant life events, developmental milestones specific to women, and IHD diagnoses or events could cue further psychological assessment and referral, efforts which will mutually strengthen the evidence for integrated psychological and IHD care and delivery of such care to this vulnerable group.

Post-traumatic stress disorder symptom remission and cognition in a large cohort of civilian women

BACKGROUND

Post-traumatic stress disorder (PTSD) is associated with cognitive impairments. It is unclear whether problems persist after PTSD symptoms remit.

METHODS

Data came from 12 270 trauma-exposed women in the Nurses' Health Study II. Trauma and PTSD symptoms were assessed using validated scales to determine PTSD status as of 2008 (trauma/no PTSD, remitted PTSD, unresolved PTSD) and symptom severity (lifetime and past-month). Starting in 2014, cognitive function was assessed using the Cogstate Brief Battery every 6 or 12 months for up to 24 months. PTSD associations with baseline cognition and longitudinal cognitive changes were estimated by covariate-adjusted linear regression and linear mixed-effects models, respectively.

RESULTS

Compared to women with trauma/no PTSD, women with remitted PTSD symptoms had a similar cognitive function at baseline, while women with unresolved PTSD symptoms had worse psychomotor speed/attention and learning/working memory. In women with unresolved PTSD symptoms, past-month PTSD symptom severity was inversely associated with baseline cognition. Over follow-up, both women with remitted and unresolved PTSD symptoms in 2008, especially those with high levels of symptoms, had a faster decline in learning/working memory than women with trauma/no PTSD. In women with remitted PTSD symptoms, higher lifetime PTSD symptom severity was associated with a faster decline in learning/working memory. Results were robust to the adjustment for sociodemographic, biobehavioral, and health factors and were partially attenuated when adjusted for depression.

CONCLUSION

Unresolved but not remitted PTSD was associated with worse cognitive function assessed six years later. Accelerated cognitive decline was observed among women with either unresolved or remitted PTSD symptoms.

Attenuated peripheral oxygen extraction and greater cardiac output in women with posttraumatic stress disorder during exercise

Posttraumatic stress disorder (PTSD) is associated with an increased risk of developing cardiovascular disease, especially in women. Evidence indicates that men with PTSD exhibit lower maximal oxygen uptake (V̇o2max) relative to controls; however, whether V̇o2max is blunted in women with PTSD remains unknown. Furthermore, it is unclear what determinants (i.e., central and/or peripheral) of V̇o2max are impacted by PTSD. Therefore, we evaluated the central (i.e., cardiac output; Q̇c) and peripheral (i.e., arteriovenous oxygen difference) determinants of V̇o2max in women with PTSD; hypothesizing that V̇o2max would be lower in women with PTSD compared with women without PTSD (controls), primarily due to smaller increases in stroke volume (SV), and therefore Q̇c. Oxygen uptake (V̇o2), heart rate (HR), Q̇c, SV, and arteriovenous oxygen difference were measured in women with PTSD (n = 14; mean [SD]: 43 [11] yr,) and controls (n = 17; 45 [11] yr) at rest, and during an incremental maximal treadmill exercise test, and the Q̇c/V̇o2 slope was calculated. V̇o2max was not different between women with and without PTSD (24.3 [5.6] vs. 26.4 [5.0] mL/kg/min; P = 0.265). However, women with PTSD had higher Q̇c [P = 0.002; primarily due to greater SV (P = 0.069), not HR (P = 0.285)], and lower arteriovenous oxygen difference (P = 0.002) throughout exercise compared with controls. Furthermore, the Q̇c/V̇o2 slope was steeper in women with PTSD relative to controls (6.6 [1.4] vs. 5.7 [1.0] AU; P = 0.033). Following maximal exercise, women with PTSD exhibited slower HR recovery than controls (P = 0.046). Thus, despite attenuated peripheral oxygen extraction, V̇o2max is not reduced in women with PTSD, likely due to larger increases in Q̇c.NEW & NOTEWORTHY The current study indicates that V̇o2max is not different between women with and without PTSD; however, women with PTSD exhibit blunted peripheral extraction of oxygen, thus requiring an increase in Q̇c to meet metabolic demand during exercise. Furthermore, following exercise, women with PTSD demonstrate impaired autonomic cardiovascular control relative to sedentary controls. We interpret these data to indicate that women with PTSD demonstrate aberrant cardiovascular responses during and immediately following fatiguing exercise.

A marginal structural model to estimate the effect of antidepressant medication treatment on major cardiovascular events among people with post-traumatic stress disorder

BACKGROUND

Previous evidence on antidepressant medication and cardiovascular disease (CVD) among patients with posttraumatic stress disorder (PTSD) has been inconclusive. We estimated the association between antidepressant medication and CVD by applying a marginal structural model.

METHODS

We analyzed medical utilization records of 27 170 people with PTSD without prior major cardiovascular events in the Korean National Health Insurance Database (NHID). PTSD and CVD were defined in accordance with the recorded ICD-10 diagnostic codes. We acquired information on antidepressant use from the NHID and categorized them by medication type. A composite major adverse cardiovascular events (MACE) outcome was defined as coronary artery disease with revascularization, ischaemic stroke, and/or haemorrhagic stroke. We used inverse probability of treatment weighting to estimate the parameters of a marginal structural discrete-time survival analysis regression model, comparing the resulting estimates to those derived from traditional time-fixed and time-varying Cox proportional hazards regression. We calculated cumulative daily defined doses to test for a dose-response relationship.

RESULTS

People exposed to antidepressants showed a higher hazard of MACE [hazard ratio (HR) 1.34, 95% confidence interval (CI) 1.18-1.53]. The estimated effects were strongest for selective serotonin reuptake inhibitors (HR 1.24, 95% CI 1.08-1.44) and TCAs (HR 1.33, 95% CI 1.13-1.56). Exposure to serotonin-norepinephrine reuptake inhibitors did not appear to increase the risk of MACE. People exposed to higher doses of antidepressants showed higher risk of MACE.

CONCLUSIONS

In a national cohort of people with PTSD, exposure to antidepressant medications increased the risk of MACE in a dose-response fashion.

Dog ownership may promote cardiometabolic health in U.S. military veterans

Dog ownership has been associated with reduced cardiovascular and all-cause mortality in civilian epidemiological samples. Associations between dog ownership and cardiometabolic disease were examined in the 2019-2020 wave of the National Health and Resilience in Veterans Study. Dog and cat ownership data were obtained from 3078 Veterans and cross-tabulated with self-reported, professionally diagnosed, heart disease, heart attack, stroke, high blood pressure, diabetes, and high cholesterol. In unadjusted tests, dog ownership was associated with lower rates of heart disease, high blood pressure, diabetes, and high cholesterol, while cat ownership was not. Relative to non-owners, dog owners were younger, were more likely to screen positive for posttraumatic stress disorder and/or major depressive disorder, and more active. Binary logistic regression models of associations between dog ownership and cardiometabolic disease were adjusted for age, sex, trauma load, mood disorder, substance abuse, nicotine abuse, and exercise. After adjustment, dog ownership was still associated with lower odds of hypertension and high cholesterol. Dog ownership also interacted with exercise to lower odds of heart disease and attenuated the effect of trauma load on hypertension. Conversely, age interacted with dog ownership such that odds of diabetes and stroke were higher in older Veterans who owned dogs.

A Mendelian randomization study of genetic liability to post-traumatic stress disorder and risk of ischemic stroke

Observational studies have shown an association between post-traumatic stress disorder (PTSD) and ischemic stroke (IS) but given the susceptibility to confounding it is unclear if these associations represent causal effects. Mendelian randomization (MR) facilitates causal inference that is robust to the influence of confounding. Using two sample MR, we investigated the causal effect of genetic liability to PTSD on IS risk. Ancestry-specific genetic instruments of PTSD and four quantitative sub-phenotypes of PTSD, including hyperarousal, avoidance, re-experiencing, and total symptom severity score (PCL-Total) were obtained from the Million Veteran Programme (MVP) using a threshold P value (P) of <5 × 10-7, clumping distance of 1000 kilobase (Mb) and r2 < 0.01. Genetic association estimates for IS were obtained from the MEGASTROKE consortium (Ncases = 34,217, Ncontrols = 406,111) for European ancestry individuals and from the Consortium of Minority Population Genome-Wide Association Studies of Stroke (COMPASS) (Ncases = 3734, Ncontrols = 18,317) for African ancestry individuals. We used the inverse-variance weighted (IVW) approach as the main analysis and performed MR-Egger and the weighted median methods as pleiotropy-robust sensitivity analyses. In European ancestry individuals, we found evidence of an association between genetic liability to PTSD avoidance, and PCL-Total and increased IS risk (odds ratio (OR)1.04, 95% Confidence Interval (CI) 1.007-1.077, P = 0.017 for avoidance and (OR 1.02, 95% CI 1.010-1.040, P = 7.6 × 10-4 for PCL total). In African ancestry individuals, we found evidence of an association between genetically liability to PCL-Total and reduced IS risk (OR 0.95 (95% CI 0.923-0.991, P = 0.01) and hyperarousal (OR 0.83 (95% CI 0.691-0.991, P = 0.039) but no association was observed for PTSD case-control, avoidance, or re-experiencing. Similar estimates were obtained with MR sensitivity analyses. Our findings suggest that specific sub-phenotypes of PTSD, such as hyperarousal, avoidance, PCL total, may have a causal effect on people of European and African ancestry's risk of IS. This shows that the molecular mechanisms behind the relationship between IS and PTSD may be connected to symptoms of hyperarousal and avoidance. To clarify the precise biological mechanisms involved and how they may vary between populations, more research is required.

Heart Rate During Sleep in PTSD Patients: Moderation by Contact with a Service Dog

There is growing interest in the potential health benefits of dog ownership in both the lay and scientific communities. Large reductions in risk for cardiovascular disease and all-cause mortality in dog owners relative to non-owners have been observed in epidemiological samples. Persons diagnosed with posttraumatic stress disorder exhibit elevated risk for cardiovascular disease. The current study tested a sample of 45 U.S. military veterans with deployment-related posttraumatic stress disorder employing an intensive, longitudinal, within-subjects design contrasting sleep heart rate on nights with and without a service dog. As participants were engaged in residential psychiatric treatment, sleep opportunities, waking activities, meals, and medications, were consistently scheduled. The primary recording methodology, mattress actigraphy, enabled passive quantification of heart rate over a total sample of 1097 nights. Service dog contact was associated with reduced sleep heart rate especially in participants with more severe PTSD. Longer-term longitudinal studies will be needed to assess the durability and asymptotic magnitude of this effect. An unexpected effect of nights in study was associated with increased heart rate consistent with hospitalization-associated deconditioning.

Posttraumatic stress disorder, diurnal cortisol, and ambulatory blood pressure in early and late pregnancy

Posttraumatic stress disorder (PTSD) affects 1 in 20 reproductive-aged women and is associated with cardiovascular disease morbidity and mortality. The pathophysiology linking PTSD to cardiovascular disease in nonpregnant adults is proposed to include hypothalamic and autonomic dysregulation; however, the pathways explaining this association in pregnancy are unclear. We examined diurnal cortisol and ambulatory blood pressure (BP) among 254 pregnant women at approximately 12 and 32 gestational weeks. Participants were, on average, 31 years old (SD = 5), 24.4% reported their ethnicity as Hispanic, and 62.2% reported their race as White. PTSD symptoms were measured using the PTSD Checklist for DSM-5 (PCL-5). Hierarchical linear regression analyses were performed to examine associations pregnancy between PTSD and cortisol at awakening, 30 min after awakening, and bedtime in early and late pregnancy, as well as associations between PTSD symptoms and daytime and nighttime systolic (SBP) and diastolic BP (DBP) and BP variability. Logistic regression analyses were conducted to test associations between PTSD symptoms and BP dipping. The results showed a positive association between PTSD symptoms and nighttime BP and BP variability at 32 gestational weeks, ∆R2 = .036-.067. PTSD symptoms were negatively associated with awakening cortisol at 12 gestational weeks in unadjusted models. These findings contribute to understanding the associations between PTSD and adverse cardiovascular conditions in pregnancy. More research is needed to replicate these findings and examine whether PTSD interventions are effective at modifying pathways and decreasing the risk for cardiovascular complications in pregnancy.

Posttraumatic Stress Disorder (PTSD) as a Risk Factor for Cardiovascular Disease: Implications for Future Research and Clinical Care

PURPOSE OF REVIEW

Posttraumatic stress disorder (PTSD) may be an important risk factor for cardiovascular disease (CVD). We explore the literature linking PTSD to CVD, potential mechanisms, interventions, and clinical implications. We outline gaps in current literature and highlight necessary future research.

RECENT FINDINGS

PTSD has been independently associated with deleterious effects on cardiovascular health through biological, behavioral, and societal pathways. There are evidence-based psychotherapeutic interventions and pharmacotherapies for PTSD that may mitigate its impact on CVD. However, there are limited studies that rigorously analyze the impact of treating PTSD on cardiovascular outcomes. Trauma-informed CVD risk stratification, education, and treatment offer opportunities to improve patient care. These approaches can include a brief validated screening tool for PTSD identification and treatment. Pragmatic trials are needed to test PTSD interventions among people with CVD and evaluate for improved outcomes.

Involvement of the brain-heart axis in the link between PTSD and cardiovascular disease

Posttraumatic stress disorder (PTSD) has long been associated with a heightened risk of cardiovascular disease (CVD). A number of mechanisms have been implicated to underlie this brain-heart axis relationship, such as altered functioning of the autonomic nervous system and increased systemic inflammation. While neural alterations have repeatedly been observed in PTSD, they are rarely considered in the PTSD-CVD link. The brain-heart axis is a pathway connecting frontal and limbic brain regions to the brainstem and periphery via the autonomic nervous system and it may be a promising model for understanding CVD risk in PTSD given its overlap with PTSD neural deficits. We first provide a summary of the primary mechanisms implicated in the association between PTSD and CVD. We then review the brain-heart axis and its relevance to PTSD, as well as findings from PTSD trials demonstrating that a number of PTSD treatments have effects on areas of the brain-heart axis. Finally, we discuss sex considerations in the PTSD-CVD link. A critical next step in this study is to determine if PTSD treatments that affect the brain-heart axis (e.g., brain stimulation that improves autonomic function) also reduce the risk of CVD.

Mortality after the 9/11 terrorist attacks among world trade center health registry enrollees with cancer

BACKGROUND

While several studies have reported the association between 9/11 exposure and cancer risk, cancer survival has not been well studied in the World Trade Center (WTC) exposed population. We examined associations of 9/11-related exposures with mortality in WTC Health Registry enrollees diagnosed with cancer before and after 9/11/2001.

PATIENTS AND METHODS

This is a longitudinal cohort study of 5061 enrollees with a first-ever primary invasive cancer diagnosis between 1995 and 2015 and followed through 2016. Based on the timing of first cancer diagnosis, pre-9/11 (n = 634) and post-9/11 (n = 4427) cancer groups were examined separately. 9/11-related exposures included witnessing traumatic events, injury on 9/11, and 9/11-related post-traumatic stress disorder (PTSD). Associations of exposures with all-cause mortality were examined using Cox proportional hazards regression. In the post-9/11 group, cancer-specific mortality was evaluated by enrollee group (WTC rescue/recovery workers vs. non-workers) using Fine and Gray's proportional sub-distribution hazard models, adjusting for baseline covariates, tumor characteristics, and treatment.

RESULTS

In the pre-9/11 group, 9/11-related exposures were not associated with all-cause mortality. In the post-9/11 group, increased risk of all-cause mortality was associated with PTSD (adjusted HR = 1.35; 95% CI = 1.11-1.65), but not with injury or witnessing traumatic events. Cancer-specific mortality was not statistically significantly associated with 9/11-related exposures. In rescue/recovery workers, increased non-cancer mortality risk was associated with PTSD (aHR = 2.13, 95% CI = 1.13-4.00) and witnessing ≥3 traumatic events (aHR = 2.00, 95% CI = 1.13-3.55).

CONCLUSIONS

We did not observe associations between 9/11-related exposures and cancer-specific mortality. Similar to findings in the non-cancer WTC exposed population, PTSD was associated with increased risk of all-cause mortality in cancer patients.

A Systematic Review of Research on Trauma and Women's Health in the Nurses' Health Study II

OBJECTIVE

To synthesize research on interpersonal trauma and women's health from the Nurses' Health Study II (NHS II) and to analyze conceptualization of interpersonal trauma across studies.

DATA SOURCES

A literature review was conducted in PubMed using a systematic search strategy.

STUDY SELECTION

Articles were included in the review if they used data from the NHS II and involved investigations of interpersonal trauma. Theoretical articles, methodologic articles, and other literature reviews involving the NHS II were excluded. Initially, the search returned 61 articles. After exclusions, 45 articles met the criteria for inclusion in the review and data extraction.

DATA EXTRACTION

Information was extracted and consolidated in an evidence table. Data included study time frame, sample, definition of trauma, outcomes studied, and journal of publication.

DATA SYNTHESIS

Trauma was not operationalized consistently across studies, even though the NHS II assessed trauma experiences in childhood, adolescence, and adulthood. Most investigations focused on childhood abuse, with investigations of childhood sexual abuse overrepresented in comparison to other abuse experiences. Authors conducting studies of trauma at any time in the life course consistently found a negative association with physical and mental health outcomes, which were increased by the presence of posttraumatic stress symptoms. Results from a small number of studies suggested a negative intergenerational impact of trauma on the children of women in the NHS II.

CONCLUSION

Interpersonal trauma across the life course was strongly associated with many leading causes of morbidity and mortality among female nurses. Trauma conceptualization and operationalization varied across studies, and future investigations should leverage the full range of trauma measures available in the NHS II data set.

Impaired sympathetic neural recruitment during exercise pressor reflex activation in women with post-traumatic stress disorder

Muscle sympathetic nerve activity (MSNA) increases during isometric exercise via increased firing of low-threshold action potentials (AP), recruitment of larger, higher-threshold APs, and synaptic delay modifications. Recent work found that women with post-traumatic stress disorder (PTSD) demonstrate exaggerated early-onset MSNA responses to exercise; however, it is unclear how PTSD affects AP recruitment patterns during fatiguing exercise. We hypothesized that women with PTSD (n = 11, 43 [11] [SD] years) would exhibit exaggerated sympathetic neural recruitment compared to women without PTSD (controls; n = 13, 40 [8] years). MSNA and AP discharge patterns (via microneurography and a continuous wavelet transform) were measured during 1 min of baseline, isometric handgrip exercise (IHG) to fatigue, 2 min of post-exercise circulatory occlusion (PECO), and 3 min of recovery. Women with PTSD were unable to increase AP content per burst compared to controls throughout IHG and PECO (main effect of group: P = 0.026). Furthermore, relative to controls, women with PTSD recruited fewer AP clusters per burst during the first (controls: ∆1.3 [1.2] vs. PTSD: ∆-0.2 [0.8]; P = 0.016) and second minute (controls: ∆1.2 [1.1] vs. PTSD: ∆-0.1 [0.8]; P = 0.022) of PECO, and fewer subpopulations of larger, previously silent axons during the first (controls: ∆5 [4] vs. PTSD: ∆1 [2]; P = 0.020) and second minute (controls: ∆4 [2] vs. PTSD: ∆1 [2]; P = 0.021) of PECO. Conversely, PTSD did not modify the AP cluster size-latency relationship during baseline, the end of IHG, or PECO (all P = 0.658-0.745). Collectively, these data indicate that women with PTSD demonstrate inherent impairments in the fundamental neural coding patterns elicited by the sympathetic nervous system during IHG and exercise pressor reflex activation.

Posttraumatic Stress Disorder and Cardiovascular Disease: State of the Science, Knowledge Gaps, and Research Opportunities

Posttraumatic stress disorder (PTSD) is characterized by a persistent maladaptive reaction after exposure to severe psychological trauma. Traumatic events that may precipitate PTSD include violent personal assaults, natural and human-made disasters, and exposure to military combat or warfare. There is a growing body of evidence for associations of PTSD with major risk factors for cardiovascular disease (CVD), such as hypertension and diabetes, as well as with major CVD outcomes, such as myocardial infarction and heart failure. However, it is unclear whether these associations are causal or confounded. Furthermore, the biological and behavioral mechanisms underlying these associations are poorly understood. Here, the available evidence on the association of PTSD with CVD from population, basic, and genomic research as well as from clinical and translational research are reviewed, seeking to identify major research gaps, barriers, and opportunities in knowledge acquisition and technology as well as research tools to support and accelerate critical research for near-term and longer-term translational research directions. Large-scale, well-designed prospective studies, capturing diverse and high-risk populations, are warranted that include uniform phenotyping of PTSD as well as broad assessment of biological and behavioral risk factors and CVD outcomes. Available evidence from functional brain imaging studies demonstrates that PTSD pathophysiology includes changes in specific anatomical brain regions and circuits, and studies of immune system function in individuals with PTSD suggest its association with enhanced immune inflammatory activity. However, establishment of animal models and human tissue biobanks is also warranted to elucidate the potential causal connection of PTSD-induced brain changes and/or inflammation with CVD pathophysiology. Emerging large-scale genome-wide association studies of PTSD will provide an opportunity to conduct mendelian randomization studies that test hypotheses regarding the presence, magnitude, and direction of causal associations between PTSD and CVD outcomes. By identifying research gaps in epidemiology and genomics, animal, and human translational research, opportunities to better justify and design future interventional trials are highlighted that may test whether treatment of PTSD or underlying neurobiological or immune dysregulation may improve or prevent CVD risk or outcomes.

Post-traumatic stress disorder and its association with stroke and stroke risk factors: A literature review

Stroke is a major cause of mortality and disability globally that has multiple risk factors. A risk factor that has recently gained more attention is post-traumatic stress disorder (PTSD). Literature searches were carried out for updated PTSD information and for the relationship between PTSD and stroke. The review was divided into two sections, one exploring PTSD as an independent risk factor for stroke, with a second concentrating on PTSD's influence on stroke risk factors. The study presents accumulating evidence that shows traumatic stress predicts stroke and is also linked to many major stroke risk factors. The review contributes knowledge to stroke aetiology and acts as a reference for understanding the relationship between PTSD and stroke. The information presented indicates that screening and identification of traumatic experience would be beneficial for directing stroke patients to appropriate psychological and lifestyle interventions. In doing so, the burden of stroke may be reduced worldwide.

A Mental Health-Informed Physical Activity Intervention for First Responders and Their Partners Delivered Using Facebook: Mixed Methods Pilot Study

BACKGROUND

First responders (eg, police, firefighters, and paramedics) are at high risk of experiencing poor mental health. Physical activity interventions can help reduce symptoms and improve mental health in this group. More research is needed to evaluate accessible, low-cost methods of delivering programs. Social media may be a potential platform for delivering group-based physical activity interventions.

OBJECTIVE

This study aims to examine the feasibility and acceptability of delivering a mental health-informed physical activity program for first responders and their self-nominated support partners. This study also aims to assess the feasibility of applying a novel multiple time series design and to explore the impact of the intervention on mental health symptoms, sleep quality, quality of life, and physical activity levels.

METHODS

We co-designed a 10-week web-based physical activity program delivered via a private Facebook group. We provided education and motivation around different topics weekly (eg, goal setting, overcoming barriers to exercise, and reducing sedentary behavior) and provided participants with a Fitbit. A multiple time series design was applied to assess psychological distress levels, with participants acting as their own control before the intervention.

RESULTS

In total, 24 participants (12 first responders and 12 nominated support partners) were recruited, and 21 (88%) completed the postassessment questionnaires. High acceptability was observed in the qualitative interviews. Exploratory analyses revealed significant reductions in psychological distress during the intervention. Preintervention and postintervention analysis showed significant improvements in quality of life (P=.001; Cohen d=0.60); total depression, anxiety, and stress scores (P=.047; Cohen d=0.35); and minutes of walking (P=.04; Cohen d=0.55). Changes in perceived social support from family (P=.07; Cohen d=0.37), friends (P=.10; Cohen d=0.38), and sleep quality (P=.28; Cohen d=0.19) were not significant.

CONCLUSIONS

The results provide preliminary support for the use of social media and a multiple time series design to deliver mental health-informed physical activity interventions for first responders and their support partners. Therefore, an adequately powered trial is required.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN): 12618001267246; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001267246.

Association of traumatic stress and posttraumatic stress disorder with carotid atherosclerosis: findings from the general population

Background: Cumulative evidence suggests that both traumatic stress and posttraumatic stress disorder (PTSD) are cross-sectionally and prospectively linked to cardiovascular disease (CVD). However, their association with proxy markers of atherosclerosis has hardly been investigated. Objective: The objective of this general population study was to relate traumatic stress and PTSD to carotid plaque and intima-media thickness (cIMT). Methods: 3119 adults from the general population were assessed regarding their traditional cardiovascular risk factors, and an ultrasound of the carotid arteries was performed in each participant. Based on a PTSD interview, every participant was assigned to one of three groups: no trauma; trauma, but no PTSD; and trauma with PTSD. The sample was stratified into five age groups. Results: Trauma exposure was reported by 54.5% of the sample and 2.0% had PTSD. Traumatized participants had increased odds of self-reported CVD events compared to those without trauma exposure, even when accounted for CVD risk factors and other covariates (odds ratio [OR] = 1.51; 95% confidence interval [CI]: 1.03-2.22). This association was driven by those aged 70 years or older. Only in those aged 40 to 49 years, there was an association between cIMT and PTSD. There were no further associations between carotid plaque or cIMT and traumatic stress or PTSD. Conclusions: Our findings in concert with prior research suggest that the association between traumatic stress, PTSD and atherosclerosis as well as its clinical endpoints is complex and remains inconclusive.

An open trial of the RECONNECT exercise program for NSW Police Officers with posttraumatic stress disorder or psychological injury

OBJECTIVE

Posttraumatic stress disorder (PTSD) and psychological injuries are debilitating health problems facing police officers. There is increasing interest in the role of exercise as an intervention. We aimed to determine the preliminary effectiveness of the RECONNECT exercise program for NSW Police Officers experiencing PTSD or psychological injury.

METHODS

An open trial was conducted between 2016 and 2017 across three NSW sites. RECONNECT consisted of twice weekly, supervised exercise sessions for three months. Outcomes were assessed at baseline, week 6 and week 12 (intervention completion) and included PTSD symptoms, depression, anxiety and stress, insomnia severity and alcohol use. Data were analysed using linear mixed models.

RESULTS

In total, n = 60 Officers were consecutively referred to the program (35% female, mean age 42.0 ± 8.9 years). The majority had a clinical diagnosis of PTSD (n = 48, 80%). A clinically significant reduction in PTSD (Cohen's d = 0.96), depression (d = 0.71), anxiety (d = 0.55) and stress (d = 0.69) symptoms was found from baseline to week 12. Drop-out and lost to follow-up was high. Higher baseline PTSD severity was associated with an increased likelihood to complete postintervention assessment.

CONCLUSIONS

RECONNECT appears to be effective in reducing symptoms of PTSD. Exercise may be an effective component of PTSD treatment.

PTSD improvement and incident cardiovascular disease in more than 1000 veterans

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with increased risk for cardiovascular disease (CVD). Whether clinically meaningful PTSD improvement is associated with lowering CVD risk is unknown.

METHODS

Eligible patients (n = 1079), were 30-70 years old, diagnosed with PTSD and used Veterans Health Affairs PTSD specialty clinics. Patients had a PTSD Checklist score (PCL) ≥ 50 between Fiscal Year (FY) 2008 and FY2012 and a second PCL score within 12 months and at least 8 weeks after the first PCL ≥ 50. Clinically meaningful PTSD improvement was defined by ≥20 point PCL decrease between the first and second PCL score. Patients were free of CVD diagnoses for 1 year prior to index. Index date was 12 months following the first PCL. Follow-up continued to FY2015. Cox proportional hazard models estimated the association between clinically meaningful PTSD improvement and incident CVD and incident ischemic heart disease (IHD). Sensitivity analysis stratified by age group (30-49 vs. 50-70 years) and depression. Confounding was controlled using propensity scores and inverse probability of exposure weighting.

RESULTS

Patients were 48.9 ± 10.9 years of age on average, 83.3% male, 60.1% white, and 29.5% black. After controlling for confounding, patients with vs. without PTSD improvement did not differ in CVD risk (HR = 1.08; 95%CI: 0.72-1.63). Results did not change after stratifying by age group or depression status. Results were similar for incident IHD.

CONCLUSIONS

Over a 2-7 year follow-up, we did not find an association between clinically meaningful PTSD improvement and incident CVD. Additional research is needed using longer follow-up.

Association Between Posttraumatic Stress Disorder and Mortality Among Responders and Civilians Following the September 11, 2001, Disaster

IMPORTANCE

Posttraumatic stress disorder (PTSD) has been associated with increased mortality, primarily in studies of veterans. The World Trade Center Health Registry (Registry) provides a unique opportunity to study the association between PTSD and mortality among a population exposed to the World Trade Center attacks in New York, New York, on September 11, 2001 (9/11).

OBJECTIVES

To assess whether 9/11-related probable PTSD (PTSD) is associated with increased mortality risk, as well as whether this association differs when including repeated measures of PTSD over time vs a single baseline assessment.

DESIGN, SETTING, AND PARTICIPANTS

A longitudinal cohort study of 63 666 Registry enrollees (29 270 responders and 34 396 civilians) was conducted from September 5, 2003, to December 31, 2016, with PTSD assessments at baseline (wave 1: 2003-2004) and 3 follow-up time points (wave 2: 2006-2007, wave 3: 2011-2012, wave 4: 2015-2016). Data analyses were conducted from December 4, 2018, to May 20, 2019.

EXPOSURES

Posttraumatic stress disorder was defined using the 17-item PTSD Checklist-Specific (PCL-S) self-report measure (score ≥50) at each wave (waves 1-4). Baseline PTSD was defined using wave 1 PCL-S, and time-varying PTSD was defined using the PCL-S assessments from all 4 waves.

MAIN OUTCOMES AND MEASURES

Mortality outcomes were ascertained through National Death Index linkage from 2003 to 2016 and defined as all-cause, cardiovascular, and external-cause mortality.

RESULTS

Of 63 666 enrollees (38 883 men [61.1%]; mean [SD] age at 9/11, 40.4 [10.4] years), 6689 (10.8%) had PTSD at baseline (responders: 2702 [9.5%]; civilians: 3987 [12.0%]). Participants who were middle aged (2022 [12.5%]), female (3299 [13.8%]), non-Latino black (1295 [17.0%]), or Latino (1835 [22.2%]) were more likely to have PTSD. During follow-up, 2349 enrollees died (including 230 external-cause deaths and 487 cardiovascular deaths). Among all enrollees in time-varying analyses, PTSD was associated with all-cause, cardiovascular, and external-cause mortality, with adjusted hazard ratios (AHRs) of greater magnitude compared with analyses examining baseline PTSD. Among responders, time-varying PTSD was significantly associated with increased risk of all-cause (AHR, 1.91; 95% CI, 1.58-2.32), cardiovascular (AHR, 1.95; 95% CI, 1.25-3.04), and external-cause (AHR, 2.40; 95% CI, 1.47-3.91) mortality. Among civilians, time-varying PTSD was significantly associated with increased risk of all-cause (AHR, 1.54; 95% CI, 1.28-1.85), cardiovascular (AHR, 1.72; 95% CI, 1.15-2.58), and external-cause (AHR, 2.11; 95% CI, 1.06-4.19) mortality.

CONCLUSIONS AND RELEVANCE

The risk of mortality differed in examination of baseline PTSD vs repeated measures of PTSD over time, suggesting that longitudinal data should be used where possible. Comparable findings between responders and civilians suggest that 9/11-related PTSD is associated with an increased mortality risk.

Family Member Incarceration, Psychological Stress, and Subclinical Cardiovascular Disease in Mexican Women (2012-2016)

Objectives. To examine the association between family member incarceration, psychological stress, and subclinical cardiovascular disease (CVD).Methods. Between 2012 and 2016, 1849 CVD-free women from the Mexican Teachers' Cohort responded to questions on family incarceration from the Life Stressor Checklist. Perceived stress and hair cortisol levels were measured in a subset of participants. Carotid intima-media thickness was measured, and carotid atherosclerosis was determined in all participants. We used multivariable quantile, linear, and logistic regression models to evaluate the association between family member incarceration, stress, and subclinical CVD.Results. Among women with a mean age of 49.7 years (SD ±5.2), 15.3% reported family member incarceration. We found that both perceived stress and hair cortisol levels were significantly higher in women with an incarcerated family member relative to women without one. After multivariable adjustment, women who reported family member incarceration had 41% (95% confidence interval = 1.04, 2.00) higher odds of carotid atherosclerosis compared with those who did not.Conclusions. Family member incarceration was associated with robust markers of stress and cardiovascular risk. Mass incarceration may have a long-lasting impact on physical health of affected families.

Posttraumatic Stress Disorder Is Associated with Increased Risk of Ovarian Cancer: A Prospective and Retrospective Longitudinal Cohort Study

Ovarian cancer is the deadliest gynecologic cancer. Chronic stress accelerates tumor growth in animal models of ovarian cancer. We therefore postulated that posttraumatic stress disorder (PTSD) may be associated with increased risk of ovarian cancer. We used data from the Nurses' Health Study II, a longitudinal cohort study with 26 years of follow-up, conducted from 1989 to 2015 with 54,710 subjects. Lifetime PTSD symptoms were measured in 2008. Self-reported ovarian cancer was validated with medical records. Risk of ovarian cancer was estimated with Cox proportional hazards models and further adjusted for known ovarian cancer risk factors (e.g., hormonal factors) and health risk factors (e.g., smoking). Fully prospective secondary analyses examined incident ovarian cancer occurring after PTSD assessment in 2008. In addition, we examined associations by menopausal status. During follow-up, 110 ovarian cancers were identified. Women with high PTSD symptoms had 2-fold greater risk of ovarian cancer versus women with no trauma exposure [age-adjusted HR = 2.10; 95% confidence interval (CI), 1.12-3.95]. Adjustment for health and ovarian cancer risk factors moderately attenuated this association (HR = 1.86; 95% CI, 0.98-3.51). Associations were similar or moderately stronger in fully prospective analyses (age-adjusted HR = 2.38; 95% CI, 0.98-5.76, N cases = 50) and in premenopausal women (HR = 3.42; 95% CI, 1.08-10.85). In conclusion, we show that PTSD symptoms are associated with increased risk of ovarian cancer. Better understanding of the underlying molecular mechanisms could lead to interventions that reduce ovarian cancer risk in women with PTSD and other stress-related mental disorders. SIGNIFICANCE: PTSD is associated with ovarian cancer risk, particularly in premenopausal women. Understanding the underlying molecular mechanisms will aid in formulating ways to reduce ovarian cancer risk associated with chronic stress.

Reduced left ventricular diastolic function in women with posttraumatic stress disorder

Women are two to three times more likely to develop posttraumatic stress disorder (PTSD) compared with men after exposure to a major trauma, and PTSD is associated with increased risk for cardiovascular disease in later life. The underlying mechanisms are unclear, but alterations in cardiac function may be involved. We hypothesized that women with PTSD have reduced left ventricular (LV) diastolic function. We studied 14 women with PTSD (PTSD group) and 14 women without PTSD (controls) using echocardiography Doppler to evaluate LV diastolic function, including peak velocities (E and A waves) in transmitral flow; diastolic, atrial kick, and systolic waveform velocities (e′, a′, and s′) in tissue Doppler; the ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/e′); and velocity of propagation ( Vp) . Baseline characteristics including age, body size, blood pressure, and heart rate were not significantly different between the two groups. Compared with the control group, women with PTSD showed greater E/e′ (controls vs. PTSD group: 7.0 ± 1.3 vs. 9.1 ± 1.3, P = 0.002) and smaller Vp (controls vs. PTSD group: 63.7 ± 11.3 vs. 47.5 ± 6.9 cm/s, P = 0.003). These results suggest that women with PTSD have reduced LV diastolic function, which may contribute, at least in part, to the increased risk of cardiovascular disease later in life.

Lifetime Trauma and Cardiometabolic Risk in Sexual Minority Women

Background: Sexual minority women (SMW; such as lesbian, bisexual, and mostly lesbian) exhibit excess cardiometabolic risk, yet factors that contribute to cardiometabolic risk in this population are poorly understood. Trauma exposure has been posited as a contributor to cardiometabolic risk in SMW. Materials and Methods: An analysis of data from Wave 3 of the Chicago Health and Life Experiences of Women Study was conducted. Multinomial logistic regression was used to examine correlates of trauma. Next, multiple logistic regression was used to examine the associations of different forms of trauma throughout the life course (childhood, adulthood, and lifetime), with psychosocial and behavioral risk factors and self-reported cardiometabolic risk (obesity, hypertension, and diabetes) in SMW adjusted for relevant covariates. Results: A total of 547 participants were included. Older age was associated with higher rates of childhood and adulthood trauma. SMW of color reported higher rates of childhood trauma than white participants. Higher education was associated with lower rates of adulthood trauma. All forms of trauma were associated with probable diagnosis of post-traumatic stress disorder and lower perceived social support. Adult trauma was associated with anxiety, whereas childhood and lifetime trauma were associated with higher odds of depression. No significant associations between forms of trauma and behavioral risk factors were noted, except that childhood trauma was associated with higher odds of past-3-month overeating. Logistic regression models examining the association of trauma and cardiometabolic risk revealed that childhood trauma was an independent risk factor for diabetes. Adulthood and lifetime trauma were significantly associated with obesity and hypertension. Conclusions: Trauma emerged as an independent risk factor for cardiometabolic risk in SMW. These findings suggest that clinicians should screen for trauma as a cardiovascular risk factor in SMW, with special attention to SMW most at risk.

Improving treatment for patients with childhood abuse related posttraumatic stress disorder (IMPACT study): protocol for a multicenter randomized trial comparing prolonged exposure with intensified prolonged exposure and phase-based treatment

BACKGROUND

Childhood abuse related posttraumatic stress disorder (CA-PTSD) is associated with a high burden of disease and with treatment response rates that leave room for improvement. One of the treatments for PTSD, prolonged exposure (PE), is effective but has high drop-out rates and remission rates are relatively low. An intensified form of PE (iPE) was associated with good response and low drop-out rates in PTSD and has not yet been tested in a controlled trial in CA-PTSD. Phase-based treatment (PBT), in which PE is preceded by skills training may improve overall outcomes in this population. We will assess the effectiveness and cost-effectiveness of standard PE, iPE and PBT in patients with CA-PTSD.

METHODS/DESIGN

Multi-center randomized controlled trial. Treatment conditions are: prolonged exposure (PE; maximum of 16 sessions in 16 weeks); intensified PE (iPE; maximum of 12 sessions in four weeks and two booster sessions); phase-based treatment (PBT; maximum of eight sessions skills training followed by eight sessions PE in 16 weeks).

PRIMARY OUTCOME

Clinician-rated PTSD symptom severity.

SECONDARY OUTCOMES

loss of PTSD diagnosis, self-reported PTSD symptom severity, comorbid symptom severity and quality of life. Moreover, we will examine cost-effectiveness and moderators and mediators of treatment outcome.

TARGET POPULATION

adults with CA-PTSD (N = 150). Assessments in weeks 0, 4, 8, 16, 26 and 52.

DISCUSSION

Given that no consensus yet exists about the treatment guidelines for patients with CA-PTSD, the present study may have important implications for the treatment of CA-PTSD.

TRAIL REGISTRATION

Registered at C.C.M.O. on Sept 7, 2016 (NL57984.058.16); retrospectively registered at June 21, 2017 at clinicaltrials.gov identifier: NCT03194113 .

PTSD and Physical Health

PURPOSE OF REVIEW

We review evidence linking PTSD to physical health symptoms and specific disorders, highlighting areas with multiple studies and objective measures of disease states when available. We also examine evidence for biological, behavioral, and psychosocial mechanisms underlying these associations and discuss the clinical implications of recent research.

RECENT FINDINGS

Recent meta-analyses have found that evidence is particularly strong for increased risk of cardiovascular, metabolic, and musculoskeletal disorders among patients with PTSD. Numerous studies have found alterations in the hypothalamic-pituitary-adrenal axis, sympathetic nervous system, inflammation, and health behaviors that could increase risk of illness, but few studies have simultaneously incorporated measures of mechanisms and disease outcomes. Future research should focus on expanding the diversity of populations studied, particularly with respect to underrepresented racial and ethnic groups. Longitudinal studies that incorporate repeated measures of PTSD, pathogenic mechanisms of disease, and physical health outcomes and the addition of physical health outcomes to PTSD treatment trials will be most informative for the field.