Physician-diagnosed medical disorders in relation to PTSD symptoms in older male military veterans

"When my mind hurts, my body hurts": Complex PTSD and chronic physical health conditions-A qualitative study exploring the factors contributing to their relationship

OBJECTIVES

Complex PTSD (cPTSD) has a high comorbidity rate with chronic physical health conditions. This is the first qualitative study to investigate what factors might be contributing to this relationship.

METHODS

Twelve participants with cPTSD and chronic physical health conditions were recruited from mental health services across London. Semi-structured interviews were completed. A reflexive thematic analysis was conducted.

RESULTS

Four themes were identified: Negative Health Behaviours; Mind-Body Link; Negative Core Beliefs about Self, Others and Health; and Negative Impact of Conditions on Wellbeing. The reciprocal relationship between cPTSD and chronic physical health conditions was highlighted: one condition was found to perpetuate or trigger the other, either directly (e.g., pain triggering flashbacks) or indirectly (interfering with treatment). Various factors were found to contribute to the relationship, including cognitive difficulties, sleep difficulties, and reduced social support.

CONCLUSIONS

The importance of recognizing mind-body links and targeting factors maintaining both cPTSD and physical health conditions is highlighted.

Associations Among PTSD, Cognitive Functioning, and Health-Promoting Behavior in Post-9/11 Veterans

INTRODUCTION

PTSD is associated with negative health behaviors that increase chronic disease risk, yet health behaviors and their determinants are not well investigated in this context. One understudied mechanism of health behaviors is cognitive functioning. Deficits in cognitive functioning may undermine engagement in health-promoting behavior, thereby increasing the negative impact of PTSD. We tested three hypotheses: (1) Greater PTSD symptom severity is associated with less health-promoting behavior; (2) greater PTSD symptom severity is associated with poorer cognitive functioning across verbal memory, processing speed, attention, and executive functioning domains; and (3) verbal memory and executive functioning exhibit indirect effects on the relationship between PTSD and health-promoting behavior.

MATERIALS AND METHODS

We examined associations between PTSD symptom severity (Clinician-Administered PTSD Scale for DSM-IV), cognitive functioning, and health-promoting behavior (Health-Promoting Lifestyle Profile II) in 124 post-9/11 veterans (average age = 37.82; 85.5% male; 63.7% White; 18.5% Black; 26.6% Hispanic). Cognitive domains examined included verbal memory (California Verbal Learning Test), processing speed (Digit Symbol Coding), attention and working memory (Digit Span), and executive functions (Trail Making Test and Stroop Interference).

RESULTS

Regression analyses indicated that greater PTSD symptom severity was associated with less health-promoting behavior (B = -.0101, SE = 0.0016, P < .0001; R2 = 0.3052). Path analyses revealed that verbal learning and memory partially accounted for this relationship (R2 = 0.037- 0.043; P < .05).

CONCLUSIONS

Therapeutic targeting of these relationships may have implications for the prevention of long-term disease impact in veterans; longitudinal research is needed to elucidate the potential impact on chronic disease.

Physical health of Post-9/11 U.S. Military veterans in the context of Healthy People 2020 targeted topic areas: Results from the Comparative Health Assessment Interview Research Study

Large-scale epidemiological studies suggest that veterans may have poorer physical health than nonveterans, but this has been largely unexamined in post-9/11 veterans despite research indicating their high levels of disability and healthcare utilization. Additionally, little investigation has been conducted on sex-based differences and interactions by veteran status. Notably, few studies have explored veteran physical health in relation to national health guidelines. Self-reported, weighted data were analyzed on post-9/11 U.S. veterans and nonveterans (n = 19,693; 6,992 women, 12,701 men; 15,160 veterans, 4,533 nonveterans). Prevalence was estimated for 24 physical health conditions classified by Healthy People 2020 targeted topic areas. Associations between physical health outcomes and veteran status were evaluated using bivariable and multivariable analyses. Back/neck pain was most reported by veterans (49.3 %), twice that of nonveterans (22.8 %)(p < 0.001). Adjusted odds ratios (AORs) for musculoskeletal and hearing disorders, traumatic brain injury, and chronic fatigue syndrome (CFS) were 3-6 times higher in veterans versus nonveterans (p < 0.001). Women versus men had the greatest adjusted odds for bladder infections (males:females, AOR = 0.08, 95 % CI:0.04-0.18)(p < 0.001), and greater odds than men for multiple sclerosis, CFS, cancer, irritable bowel syndrome/colitis, respiratory disease, some musculoskeletal disorders, and vision loss (p < 0.05). Cardiovascular-related conditions were most prominent for men (p < 0.001). Veteran status by sex interactions were found for obesity (p < 0.03; greater for male veterans) and migraine (p < 0.01; greater for females). Healthy People 2020 targeted topic areas exclude some important physical health conditions that are associated with being a veteran. National health guidelines for Americans should provide greater consideration of veterans in their design.

Self-reported gastrointestinal disorders among veterans with gulf war illness with and without posttraumatic stress disorder

BACKGROUND

Gulf War Illness (GWI) is a chronic, multi-symptom disorder affecting 25%-32% of Gulf War veterans. Veterans with GWI disproportionately suffer from gastrointestinal (GI) disorders. Given the increasing evidence supporting a gut-brain axis, we explore the relationship between post-traumatic stress disorder (PTSD), GWI, and self-reported GI disorders among GW veterans.

METHODS

Veterans from the Gulf War Era Cohort and Biorepository responded to a mail-based survey (N = 1058). They were stratified by GWI (Centers for Disease Control definition) and PTSD status. This yielded three groups: GWI-, GWI+/PTSD-, and GWI+/PTSD+. Multivariable logistic regression adjusting for demographic and military characteristics examined associations between GWI/PTSD groups and GI disorders. Results were expressed as adjusted odds ratios (aOR) with 95% confidence intervals (95% CI).

KEY RESULTS

The most frequently reported GI disorders were irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), and colon polyps (CP). The GWI+/PTSD+ group had a higher odds of these disorders than the GWI+/PTSD- group (aOR_IBS  = 3.12, 95% CI: 1.93-5.05; aOR_GERD  = 2.04, 95% CI: 1.44-2.90; aOR_CP  = 1.85, 95% CI: 1.23-2.80), which had a higher odds of these disorders than the GWI- group (aOR_IBS  = 4.38, 95% CI: 1.55-12.36; aOR_GERD  = 2.51 95% CI: 1.63-3.87; aOR_CP  = 2.57, 95% CI: 1.53-4.32).

CONCLUSIONS & INFERENCES

GW veterans with GWI and PTSD have significantly higher odds of specific self-reported GI disorders than the other groups. Given the known bidirectional influences of the gut and brain, these veterans may benefit from a holistic healthcare approach that considers biopsychosocial contributors to the assessment and management of disease.

Screening for opioid use disorder and co-occurring depression and post-traumatic stress disorder in primary care in New Mexico

BACKGROUND

Identifying patients in primary care services with opioid use disorder and co-occurring mental health disorders is critical to providing treatment. Objectives of this study were to (1) assess the feasibility of recruiting people to screen in-person for opioid use disorder and co-occurring mental health disorders (depression and/or post-traumatic stress disorder) in primary care clinic waiting rooms in preparation for a randomized controlled trial, and (2) compare results of detecting these disorders by universal in-person screening compared to electronic health record (EHR) diagnoses.

METHODS

This cross-sectional feasibility and pilot study recruited participants from four primary care clinics, two rural and two urban, from three health care organizations in New Mexico. Inclusion criteria were adults (≥ 18 years), attending one of the four clinics as a patient, and who spoke English or Spanish. Exclusion criteria were people attending the clinic for a non-primary care visit (e.g., dental, prescription pick up, social support). The main outcomes and measures were (1) recruitment feasibility which was assessed by frequencies and proportions of people approached and consented for in-person screening, and (2) relative differences of detecting opioid use disorder and co-occurring mental health disorders in waiting rooms relative to aggregate EHR data from each clinic, measured by prevalence and prevalence ratios.

RESULTS

Over two-weeks, 1478 potential participants were approached and 1145 were consented and screened (77.5% of patients approached). Probable opioid use disorder and co-occurring mental health disorders were identified in 2.4% of those screened compared to 0.8% in EHR. Similarly, universal screening relative to EHR identified higher proportions of probable opioid use disorder (4.5% vs. 3.4%), depression (17.5% vs. 12.7%) and post-traumatic stress disorder (19.0% vs. 3.6%).

CONCLUSIONS

Universal screening for opioid use disorder, depression, and post-traumatic stress disorder was feasible, and identified three times as many patients with these co-occurring disorders compared to EHR. Higher proportions of each condition were also identified, especially post-traumatic stress disorder. Results support that there are likely gaps in identification of these disorders in primary care services and demonstrate the need to better address the persistent public health problem of these co-occurring disorders.

Post-traumatic stress disorder as a predictor for incident hypertension: a 3-year retrospective cohort study

BACKGROUND

The goal of the present study was to investigate the association between PTSD and the onset of hypertension in previously normotensive individuals in a population living in the stressful environment of the urban slums while controlling for risk factors for cardiovascular disease (CVD).

METHODS

Participants were 320 normotensive individuals who lived in slums and were attending a family doctor program. Measurements included a questionnaire covering sociodemographic characteristics, clinical status and life habits, the Posttraumatic Stress Disorder Checklist - Civilian Version, and the Beck Depression Inventory. Incident hypertension was defined as the first occurrence at the follow-up review of the medical records of (1) systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher, (2) the participant started taking antihypertensive medication, or (3) a new diagnosis of hypertension made by a physician. Differences in sociodemographic, clinical, and lifestyle characteristics between hypertensive and non-hypertensive individuals were compared using the χ² and t tests. Multivariate Cox proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

Six variables - age, educational level, body mass, smoking, diabetes, and PTSD diagnosis - showed a statistically significant (p ≤ 0.20) association with the hypertensive status. In the Cox regression, only PTSD diagnosis was significantly associated with incident hypertension (multivariate HR = 1.94; 95% CI 1.11-3.40).

CONCLUSIONS

The present findings highlight the importance of considering a diagnostic hypothesis of PTSD in the prevention and treatment of cardiovascular diseases.

Social Functioning in Individuals With Post-Traumatic Stress Disorder: A Systematic Review

Post-traumatic stress disorder (PTSD) can lead to multiple deleterious outcomes and has negative, sometimes debilitating, impacts on general functioning of those affected. This systematic review of 26 articles evaluates the existing literature on social functioning outcomes used in PTSD research, the association between PTSD and social functioning, and the impact of interventions for PTSD on social functioning. A review of 26 articles using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines for systematic reviews showed that PTSD was associated with significant impairment in global social functioning. This review also reveals the need for both standardized definitions and better assessment methods to operationalize social functioning and improve our ability to compare findings across studies. The literature also suggests that some evidence-based treatments for PTSD improve social functioning despite not explicitly targeting social functioning in the treatment. The findings of this review suggest that there are ample opportunities for improving both research and interventions to improve global social functioning in PTSD.

The ambivalence about accepting the prevalence somatic symptoms in PTSD: Is PTSD a somatic disorder?

This study examined the prevalence of somatic symptoms in post-traumatic stress disorder (PTSD) in a population-based military sample (N = 14,445). Descriptive statistics explored somatic symptom endorsement in the entire sample. A latent class analyses was conducted on participants with a posttraumatic stress checklist (PCL) score ≥29 (n = 2433), with class differentiated by somatic symptom endorsement.Multinomial logistic regression explored correlates of latent class. Somatic disorder was more prevalent in probable-PTSD (59.6%) and subsyndromal-PTSD (26.5%) than no-PTSD (5.0%) groups, supporting an intersection of pathophysiological processes between somatic and PTSD symptoms. A 3-class solution of Syndromal (26.7%),Psychological (17.7%), and Somatic (55.5%) classes provided the optimal representation of latent somatic symptom typologies in probable PTSD and subsyndromal PTSD. Differences between classes on key characteristics supported potentially meaningful class distinctions. Class was not predicted by number of deployments nor whether a member had ever deployed. However, class was predicted by life-time trauma, indicating that the PTSD somatic symptom relationship is not confined to combat related PTSD or the effect of toxic exposures on deployment, but that pre-existing pathophysiology related to life-time trauma may drive the relationship.The high degree of coincidence between PTSD and somatic symptoms and the high prevalence of somatic distress in the Syndromal and Somatic classes support somatic symptoms are a ubiquitous aspect of the clinical presentation and should be considered a central characteristic of PTSD and therefore included in the diagnostic criteria, as suggested by the original formulations of PTSD.

Examining Individual and Synergistic Contributions of PTSD and Genetics to Blood Pressure: A Trans-Ethnic Meta-Analysis

Growing research suggests that posttraumatic stress disorder (PTSD) may be a risk factor for poor cardiovascular health, and yet our understanding of who might be at greatest risk of adverse cardiovascular outcomes after trauma is limited. In this study, we conducted the first examination of the individual and synergistic contributions of PTSD symptoms and blood pressure genetics to continuous blood pressure levels. We harnessed the power of the Psychiatric Genomics Consortium-PTSD Physical Health Working Group and investigated these associations across 11 studies of 72,224 trauma-exposed individuals of European (n = 70,870) and African (n = 1,354) ancestry. Genetic contributions to blood pressure were modeled via polygenic scores (PGS) for systolic blood pressure (SBP) and diastolic blood pressure (DBP) that were derived from a prior trans-ethnic blood pressure genome-wide association study (GWAS). Results of trans-ethnic meta-analyses revealed significant main effects of the PGS on blood pressure levels [SBP: β = 2.83, standard error (SE) = 0.06, p < 1E-20; DBP: β = 1.32, SE = 0.04, p < 1E-20]. Significant main effects of PTSD symptoms were also detected for SBP and DBP in trans-ethnic meta-analyses, though there was significant heterogeneity in these results. When including data from the largest contributing study - United Kingdom Biobank - PTSD symptoms were negatively associated with SBP levels (β = -1.46, SE = 0.44, p = 9.8E-4) and positively associated with DBP levels (β = 0.70, SE = 0.26, p = 8.1E-3). However, when excluding the United Kingdom Biobank cohort in trans-ethnic meta-analyses, there was a nominally significant positive association between PTSD symptoms and SBP levels (β = 2.81, SE = 1.13, p = 0.01); no significant association was observed for DBP (β = 0.43, SE = 0.78, p = 0.58). Blood pressure PGS did not significantly moderate the associations between PTSD symptoms and blood pressure levels in meta-analyses. Additional research is needed to better understand the extent to which PTSD is associated with high blood pressure and how genetic as well as contextual factors may play a role in influencing cardiovascular risk.

Do somatic symptoms relate to PTSD and gender after earthquake exposure? A cross-sectional study on young adult survivors in Italy

OBJECTIVE

Increasing evidence confirms a strict relationship between mental disorders and physical health. Particularly, stressful life events and post-traumatic stress disorder (PTSD) have been closely correlated with various physical disorders and somatic symptoms, such as chronic pain, gastrointestinal disorders, and headaches. The aim of this study was to investigate the emergence of somatic symptoms in a sample of young adult survivors 21 months after exposure to the L'Aquila 2009 earthquake, with particular attention to PTSD and gender impact.

METHODS

Four hundred and fifty high-school senior students (253 male and 197 female) exposed to the 2009 L'Aquila earthquake, 21 months earlier, were enrolled and evaluated by the Trauma and Loss Spectrum Self-Report (TALS-SR), for symptomatological PTSD, and the Mood Spectrum Self-Report-Lifetime Version (MOODS-SR) "rhythmicity and vegetative functions" domain, for somatic symptoms.

RESULTS

Significantly higher rates of endorsement of the MOODS-SR somatic symptoms emerged in survivors with PTSD compared to those without. Females reported higher rates of endorsement of at least one MOODS-SR somatic symptom compared to males; however, a Decision Tree model and a two-way analysis of variance model confirmed a significant effect of PTSD only. A multivariate logistical regression showed a significant association between the presence of at least one MOOD-SR somatic symptom and re-experiencing and maladaptive coping TALS-SR domains.

CONCLUSION

This study corroborates a relevant impact of symptomatological PTSD, across both the genders, on somatic symptoms occurring in young adults after months from exposure to a massive earthquake.

Associations between posttraumatic stress symptoms, perceived social support and psychological distress among disaster-exposed Chinese young adults: A three-wave longitudinal mediation model

Research has documented a strong association between perceived social support, posttraumatic stress symptoms (PTSS), and psychological distress (PD) among people exposed to natural disasters. However, the direction of associations between these factors remains unclear. This study examined possible mediational relationships among perceived social support, PTSS, and PD. A three-wave longitudinal design (6 months intervals) was employed in a sample of 341 Chinese university students (M_age = 21.24, SD = 2.72; 75.7% female) aged 18 to 34 who were directly exposed to a typhoon that occurred in Macao, China, during August 2017. Results indicated that perceived social support at T2 mediated the linkage between PTSS at T1 and PD at T3, and that PTSS at T2 significantly mediated the relationship between PD at T1 and perceived social support at T3. This three-wave longitudinal study highlights the key role of perceived social support on the aggravating effect of acute PTSS on long-term psychological problems, and demonstrates that adverse psychological health outcomes negatively affect the perception of supportive social resources in the context of a natural disaster.

Distress and Resilience in Resettled Refugees of War: Implications for Screening

There is little work published about predictors of specific trajectory types of distress in refugees of war during early resettlement in a host country. Data about distress (Refugee Health Screener—15 (RHS-15)) and possible predictors of distress were collected at the domestic medical examination (T1) within 90 days of arrival and the civil surgeon examination (T2) 11–16 months after T1 for refugee groups from three countries (COU). Descriptive, correlative, analyses of variance, and regression techniques were used to determine trajectory type and their predictors. A higher percentage (7.3%) were distressed at T2 than at T1. By group, the Bhutanese became more distressed, the Burmese became less distressed, and Iraqi’s continued to have high distress. A regression model showed gender, loss, post-migration stress, and self-efficacy to be significant predictors of trajectory type (R² = 0.46). When the T1 RHS-15 score was added to the model, observed variance increased (R² = 0.53) and T1 RHS score accounted for the majority of variance (r = 0.64, p < 0.001), with post-migration stress accounting for markedly less (β = 0.19, p = 0.03). Loss and self-efficacy became less significant. Loss was, however, a strong predictor of delayed and chronic distress trajectory type. These data suggest that screening for distress should occur at least twice during resettlement to detect those with initial distress and those with delayed distress. Screening should be coupled with identifying other social determinants of health and a comprehensive assessment to determine the need for intervention for secondary prevention (i.e., reducing delayed distress) and treatment (reducing chronic distress).

Evaluating the impact of trauma and PTSD on epigenetic prediction of lifespan and neural integrity

Post-traumatic stress disorder (PTSD) is a debilitating disorder that develops in some people following trauma exposure. Trauma and PTSD have been associated with accelerated cellular aging. This study evaluated the effect of trauma and PTSD on accelerated GrimAge, an epigenetic predictor of lifespan, in traumatized civilians. This study included 218 individuals with current PTSD, 427 trauma-exposed controls without any history of PTSD and 209 subjects with lifetime PTSD history who are not categorized as current PTSD cases. The Traumatic Events Inventory (TEI) and Clinician-Administered PTSD Scale (CAPS) were used to measure lifetime trauma burden and PTSD, respectively. DNA from whole blood was interrogated using the MethylationEPIC or HumanMethylation450 BeadChips. GrimAge estimates were calculated using the methylation age calculator. Cortical thickness of 69 female subjects was assessed by using T1-weighted structural MRI images. Associations between trauma exposure, PTSD, cortical thickness, and GrimAge acceleration were tested with multiple regression models. Lifetime trauma burden (p = 0.03), current PTSD (p = 0.02) and lifetime PTSD (p = 0.005) were associated with GrimAge acceleration, indicative of a shorter predicted lifespan. The association with lifetime PTSD was replicated in an independent cohort (p = 0.04). In the MRI sub sample, GrimAge acceleration also associated with cortical atrophy in the right lateral orbitofrontal cortex (padj = 0.03) and right posterior cingulate (padj = 0.04), brain areas associated with emotion-regulation and threat-regulation. Our findings suggest that lifetime trauma and PTSD may contribute to a higher epigenetic-based mortality risk. We also demonstrate a relationship between cortical atrophy in PTSD-relevant brain regions and shorter predicted lifespan.

Increased Vascular Pathology in Older Veterans With a Purple Heart Commendation or Chronic Post-Traumatic Stress Disorder

The goal of this retrospective cohort study was to determine whether stressors related to military service, determined by a diagnosis of chronic post-traumatic stress disorder (cPTSD) or receiving a Purple Heart (PH), are associated with an increased risk of vascular risk factors and disease, which are of great concern for veterans, who constitute a significant portion of the aging US population. The Veterans Integrated Service Network (VISN) 16 administrative database was searched for individuals 65 years or older between October 1, 1997 to September 30, 1999 who either received a PH but did not have cPTSD (PH+/cPTSD-; n = 1499), had cPTSD without a PH (PH-/cPTSD+; n = 3593), had neither (PH-/cPTSD-; n = 5010), or had both (PH+/cPTSD+; n = 153). In comparison to the control group (PH-/cPTSD-), the PH+/cPTSD- group had increased odds ratios for incidence and prevalence of diabetes mellitus, hypertension, and hyperlipidemia. The PH-/cPTSD+ group had increased odds ratios for prevalence of diabetes mellitus and for the incidence and prevalence of hyperlipidemia. The PH-/cPTSD+ and PH+/cPTSD- groups were associated with ischemic heart disease and cerebrovascular disease, but not independently of the other risk factors. The PH+/cPTSD+ group was associated only with an increase in the incidence and prevalence of hyperlipidemia, though this group's much smaller sample size may limit the reliability of this finding. We conclude that certain physical and psychological stressors related to military service are associated with a greater incidence of several vascular risk factors in veterans aged 65 years or older, which in turn are associated with greater rates of ischemic heart disease and cerebrovascular disease.

Clinically meaningful posttraumatic stress disorder (PTSD) improvement and incident hypertension, hyperlipidemia, and weight loss

OBJECTIVE

Posttraumatic stress disorder (PTSD) is associated with increased risk for cardiometabolic disease. Clinically meaningful PTSD improvement is associated with a lower risk for diabetes, but it is not known if similar associations exist for incident hypertension, hyperlipidemia, and clinically relevant weight loss (i.e., ≥5% loss).

METHOD

Medical record data from Veterans Health Affairs patients with clinic encounters between fiscal year (FY) 2008 to 2015 were used to identify patients with worsening or no PTSD improvement (i.e., PTSD checklist (PCL) score decrease <10), small (10-19 point PCL decrease), and large (≥20 point PCL decrease) PTSD improvement. To estimate the association between degree of PTSD improvement and incident hypertension (n = 979), incident hyperlipidemia (n = 1,139) and incident ≥5% weight loss (1,330), we computed Cox proportional hazard models, controlling for confounding using inverse probability of exposure weighting (IPEW).

RESULTS

Overall, patients were about 40 years of age, 80% male and 65% White. Worsening or no PCL change occurred in about 60%, small improvement in 20%, and large improvement in 20%. After weighting data, compared with worsening or no change, both small and large PTSD improvements were associated, albeit not significantly, with lower risks for hypertension (HR = 0.68; 95% confidence interval, CI [0.46, 1.01] and HR = 0.79; 95% CI [0.53, 1.18], respectively). In weighted data, PTSD improvement was not associated with incident hyperlipidemia or ≥5% weight loss.

CONCLUSIONS

We observed limited evidence for an association between PTSD improvement and decreased hypertension risk. PCL decreases were not associated with hyperlipidemia or ≥5% weight loss. Further studies that measure potential physical health benefits of change in specific PTSD symptoms are needed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Influence of Social Exclusion on Posttraumatic Stress Reactions in Older Adult Veterans

The relationship between social exclusion and posttraumatic stress reactions in aging veterans is a particularly timely issue, warranting greater attention in the social work literature. Research with military veterans indicates that the social marginalization resulting from racial and ethnic discrimination can exacerbate posttraumatic stress symptoms. This marginalization suggests an increased potential for emergent or recurrent trauma reactions in aging military veterans, as previous research has documented older adults' unique risk for social exclusion. The issue takes on greater relevance as increased numbers of Vietnam veterans enter older adulthood. Professionals working with military veterans should be aware of the social and cultural factors that play a critical role in posttrauma response and recovery.

Impact of Wartime Stress Exposures and Mental Health on Later-Life Functioning and Disability in Vietnam-Era Women Veterans: Findings From the Health of Vietnam-Era Women's Study

OBJECTIVE

The effect of stress exposures and mental health sequelae on health-related outcomes is understudied among older women veterans. We examined a) the impact of wartime stress exposures on later-life functioning and disability in Vietnam-era women veterans and b) the extent to which mental health conditions known to be associated with stress-posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD)-are associated with additional later-life functioning and disability.

METHODS

Data were collected in 2011 to 2012 using a mail survey and telephone interview of 4219 women veterans who were active duty during the Vietnam Era. Health functioning was assessed using the Veterans RAND 36-Item Health Survey, and disability was assessed using the World Health Organization Disability Assessment Schedule 2.0. Wartime exposures were assessed using the Women's War-Zone Stressor Scale-Revised; the Composite International Diagnostic Interview, version 3.0 was used to assess PTSD, MDD, and GAD.

RESULTS

Several wartime stress exposures-including job-related pressures, dealing with death, and sexual discrimination and harassment-were associated with worse later-life health (β ranges, -0.04 to -0.26 for functioning, 0.05 to 0.30 for disability). Current PTSD was linked with lower health functioning (physical, β = -0.06; mental, β = -0.15) and greater disability (β = 0.14). Current MDD and GAD were also associated with lower mental health functioning (MDD, β = -0.29; GAD, β = -0.10) and greater disability (MDD, β = 0.16; GAD, β = 0.06).

CONCLUSIONS

Results underscore the importance of detection and treatment of the potential long-term effects of wartime stressors and mental health conditions among women veterans.

Psychiatric comorbidity and co-occurring opioid misuse: Depression mediates the relationship between post-traumatic stress disorder and opioid misuse in community pharmacy settings

AbstractsBackground: Individuals who misuse opioids frequently have comorbid psychiatric issues, including post-traumatic stress disorder (PTSD) and depression. However, little is known about the mechanisms by which these disorders are associated with opioid misuse and specifically in community pharmacy settings. The current study examined whether depression mediated the relationship between PTSD and opioid misuse in patients filling opioid prescriptions. Methods: We administered a health survey in four community pharmacies among patients filling opioid medications in southwestern Pennsylvania. Univariate statistics were used to assess relationships among demographic and clinical characteristics of PTSD, depression, and opioid misuse behaviors. We then examined whether depression mediated the relationship between PTSD and opioid misuse using ordinary least squares path analysis with bootstrapping. Results: A total of 333 participants completed the health survey. Opioid misuse was reported among 15.9% of all participants, 33.3% among those with a positive PTSD screen, and 29.3% of those who screened positive for depression. Depression significantly mediated the relationship between PTSD and opioid misuse. Specifically, there was a statistically significant indirect effect (ab) of PTSD on opioid misuse through a pathway mediated by depression (ab = .06, SE_ab = .02, 95% CI = .02-.10). The direct effect (c') of PTSD on opioid misuse was also significant (c' = .12, SE_c' = .05, P = .01, 95% CI = .03-.22), suggesting partial mediation. Conclusions: Results suggest an indirect pathway by which clinical intervention may help ameliorate outcomes in patients with PTSD. Further, there is an increased need for screening, assessment, and intervention protocols for this patient population in which community pharmacy is a novel setting to expand future efforts within the patient population.

The Impacts of Service Related Exposures on Trajectories of Mental Health Among Aging Veterans

Objectives

Drawing on life-course perspective and cumulative advantage theory, we examined whether service related exposures (SREs)-combat and exposure to death-have lasting impacts on depressive symptom and psychiatric problem trajectories of aging veterans.

Methods

The Health and Retirement Study and linked 2013 Veterans Mail Survey were used to examine SREs and mental health among older veterans between 2002 and 2012 (N = 1,662). Latent growth curves were used to measure how individuals vary from average mental health trajectories based on SREs and other important covariates.

Results

Exposure to death had a significant and lasting effect on depressive symptoms for veterans in late life but was reduced to nonsignificance when physical health trajectories were included. Combat and exposure to death had independent and robust impacts on psychiatric problems, which were robust in final models.

Discussion

SREs presented varied and significant impacts, suggesting that combat does not work alone in driving poor mental health trajectories, and that exposure to death is a more robust risk marker for later outcomes.

Posttraumatic Stress Disorder in Older Adults: A Conceptual Review

Objectives: We provide a review of the literature on posttraumatic stress disorder (PTSD) in older adults, focusing largely on older U.S. military veterans in two primary areas: 1) assessment and diagnosis and 2) non-pharmacological treatment of PTSD in late life. Methods: We performed a search using PubMed and Academic Search Premier (EBSCO) databases and reviewed reference sections of selected papers. We also drew on our own clinical perspectives and reflections of seven expert mental health practitioners. Results: Rates of PTSD are lower in older compared with younger adults. The presence of sub-syndromal/partial PTSD is important and may impact patient functioning. Assessment requires awareness and adaptation for potential differences in PTSD experience and expression in older adults. Psychotherapies for late-life PTSD appear safe, acceptable and efficacious with cognitively intact older adults, although there are relatively few controlled studies. Treatment adaptations are likely warranted for older adults with PTSD and co-morbidities (e.g., chronic illness, pain, sensory, or cognitive changes). Conclusions: PTSD is an important clinical consideration in older adults, although the empirical database, particularly regarding psychotherapy, is limited. Clinical Implications: Assessment for trauma history and PTSD symptoms in older adults is essential, and may lead to increased recognition and treatment.

Polydrug use disorders in individuals with opioid use disorder

BACKGROUND

Understanding the association of polydrug use disorders (PUD) with psychosocial and clinical factors is essential for the treatment of individuals with opioid use disorder (OUD). The aim of this study is to examine whether there is an association between childhood maltreatment, mood disorders, anxiety disorders, personality disorders, or posttraumatic stress disorder (PTSD) and PUD in individuals with OUD.

METHODS

We used data from 356 individuals with OUD in the past 12 months from a nationally representative database in the United States. PUD patients were classified into two groups: a group with additional one substance disorder (OUD + 1) and that with two or more additional substance disorders (OUD + 2). We conducted multivariate logistic regression to predict the PUD status, after adjustment for confounders including childhood maltreatment.

RESULTS

Among all individuals, 57.3% were polydrug users (n = 204) and 42.7% were not (n = 152). There was a high prevalence of childhood maltreatment in both groups, ranging from 16.1% to 59.5%, but the difference was not statistically significant. After adjustment for confounders, we found an association between past-year PTSD and OUD + 2 (odds ratio: 3.98; 95% confidence interval: 1.15-13.72; p = 0.03) but not with OUD + 1.

CONCLUSION

PTSD is highly prevalent in individuals with OUD using multiple substances and could influence PUD. We recommend screening for PTSD in cases of PUD. Future studies should evaluate the effect of PTSD treatment on PUD.

Cannabis Use and Anxiety Sensitivity in Relation to Physical Health and Functioning in post-9/11 Veterans

Frequency of cannabis use and cognitive vulnerabilities such as anxiety sensitivity (i.e., the fear of bodily sensations), have been independently linked with poor physical health, however the interplay between these health-mental health processes may compound poor physical health and functioning in cannabis users. Thus, the current study evaluated the direct and interactive effects of cannabis use frequency and anxiety sensitivity on physical health and functioning among cannabis-using veterans. Participants (N = 138) were post-9/11 United States veterans recruited from a Veterans Affairs hospital who reported cannabis use in the past six months. Cannabis use frequency in the past month and anxiety sensitivity were significantly negatively correlated with perceived overall physical health. There was a significant interaction between cannabis use frequency and anxiety sensitivity, such that more frequent cannabis use was associated with poorer overall health and role functioning due to health problems among veterans with higher anxiety sensitivity (but not lower). Findings suggest that anxiety sensitivity is a cognitive vulnerability linked to poor perceived physical health and impairment among frequent cannabis users and could be targeted, along with cannabis use, for health-promotion in cannabis users.

Assessment of Moral Injury in Veterans and Active Duty Military Personnel With PTSD: A Review

Background: Moral injury (MI) involves distress over having transgressed or violated core moral boundaries, accompanied by feelings of guilt, shame, self-condemnation, loss of trust, loss of meaning, and spiritual struggles. MI is often found in Veterans and Active Duty Military personnel with posttraumatic stress disorder (PTSD). MI is widespread among those with PTSD symptoms, adversely affects mental health, and may increase risk of suicide; however, MI is often ignored and neglected by mental health professionals who focus their attention on PTSD only. Methods: A review of the literature between 1980 and 2018 conducted in 2018 is presented here to identify scales used to assess MI. Databases used in this review were PsychInfo, PubMed (Medline), and Google Scholar. Search terms were "moral injury," "measuring," "screening," "Veterans," and "Active Duty Military." Inclusion criteria were quantitative measurement of MI and health outcomes, Veteran or Active Duty Military status, and peer-review publication. Excluded were literature reviews, dissertations, book chapters, case reports, and qualitative studies. Results: Of the 730 studies identified, most did not meet eligibility criteria, leaving 118 full text articles that were reviewed, of which 42 did not meet eligibility criteria. Of the remaining 76 studies, 34 were duplicates leaving 42 studies, most published in 2013 or later. Of 22 studies that assessed MI, five used scales assessing multiple dimensions, and 17 assessed only one or two aspects (e.g., guilt, shame, or forgiveness). The remaining 20 studies used one of the scales reported in the first 22. Of the five scales assessing multiple dimensions of MI, two assess both morally injurious events and symptoms and the remaining three assess symptoms only. All studies were cross-sectional, except three that tested interventions. Conclusions: MI in the military setting is widespread and associated with PTSD symptom severity, anxiety, depression, and risk of suicide in current or former military personnel. Numerous measures exist to assess various dimensions of MI, including five multidimensional scales, although future research is needed to identify cutoff scores and clinically significant change scores. Three multidimensional measures assess MI symptoms alone (not events) and may be useful for determining if treatments directed at MI may both reduce symptoms and impact other mental health outcomes including PTSD.

Posttraumatic Stress Disorder and Cancer Risk: A Nested Case-Control Study

Data regarding cancer risk for individuals who were exposed to traumatic and stressful life events are conflicting. We sought to evaluate the association between posttraumatic stress disorder (PTSD) and the risk of the four most common solid tumors: lung, breast, prostate, and colorectal cancers. We conducted four nested case-control studies using a large UK population-based database. Cases were defined as individuals with any medical code for the specific malignancy. For every case, we used incidence-density sampling to match four controls by age, sex, practice site, and both duration and calendar time of follow-up. Exposure of interest was any diagnosis of PTSD prior to cancer diagnosis. The odds ratios (ORs) and 95% confidence intervals (CIs) for cancer risk associated with PTSD were estimated using multivariable conditional logistic regression and were adjusted for smoking status, obesity, and antidepressant use. The study population included four case groups according to cancer type. There were 19,143 cases with lung cancer (74,473 matched controls), 22,163 cases with colorectal cancer (86,538 matched controls), 31,352 cases with breast cancer (123,285 matched controls), and 27,212 cases with prostate cancer (105,940 matched controls). There was no statistically significant association between PTSD and cancer risk among any of the cancer types: lung, OR = 0.73, 95% CI [0.43, 1.23]; breast, OR = 0.73, 95% CI [0.52, 1.01]; prostate, OR = 1.24, 95% CI [0.87, 1.77]; and colorectal, OR = 1.05, 95% CI [0.68, 1.62]. Our findings indicated that participants in our study with PTSD were not at increased risk of lung, breast, prostate, and colorectal cancers.

Traumatic stress and accelerated DNA methylation age: A meta-analysis

BACKGROUND

Recent studies examining the association between posttraumatic stress disorder (PTSD) and accelerated aging, as defined by DNA methylation-based estimates of cellular age that exceed chronological age, have yielded mixed results.

METHODS

We conducted a meta-analysis of trauma exposure and PTSD diagnosis and symptom severity in association with accelerated DNA methylation age using data from 9 cohorts contributing to the Psychiatric Genomics Consortium PTSD Epigenetics Workgroup (combined N = 2186). Associations between demographic and cellular variables and accelerated DNA methylation age were also examined, as was the moderating influence of demographic variables.

RESULTS

Meta-analysis of regression coefficients from contributing cohorts revealed that childhood trauma exposure (when measured with the Childhood Trauma Questionnaire) and lifetime PTSD severity evidenced significant, albeit small, meta-analytic associations with accelerated DNA methylation age (ps = 0.028 and 0.016, respectively). Sex, CD4T cell proportions, and natural killer cell proportions were also significantly associated with accelerated DNA methylation age (all ps < 0.02). PTSD diagnosis and lifetime trauma exposure were not associated with advanced DNA methylation age. There was no evidence of moderation of the trauma or PTSD variables by demographic factors.

CONCLUSIONS

Results suggest that traumatic stress is associated with advanced epigenetic age and raise the possibility that cells integral to immune system maintenance and responsivity play a role in this. This study highlights the need for additional research into the biological mechanisms linking traumatic stress to accelerated DNA methylation age and the importance of furthering our understanding of the neurobiological and health consequences of PTSD.

Posttraumatic Stress Disorder and Gastrointestinal Disorders in the Danish Population

BACKGROUND

Evidence for the association between posttraumatic stress disorder (PTSD) and gastrointestinal (GI) disorders is mixed, owing in part to methodologic differences across studies. Furthermore, studies which have combined GI disorders or symptoms for examination as one overall category may potentially obscure associations between PTSD and individual GI diagnoses.

METHODS

This nationwide cohort study examined the incidence of all major nonmalignant GI disorders in patients with a prior PTSD diagnosis (n = 4,076), compared with the general population incidence from 1995 to 2013, using Danish medical registry data. We examined differences by sex, age, marital status, psychiatric and somatic comorbidity, and follow-up time. Risks, standardized incidence rates (SIRs), and confidence intervals (95% CIs) were calculated.

RESULTS

Risk of any GI disorder among PTSD patients was 25% (95% CI: 21%, 29%); the SIR for any GI disorder was 1.8 (95% CI: 1.7, 2.0). Risk and SIRs varied by disorder (e.g., no association with diverticula of the intestines [SIR: 1.1, 95% CI: 0.83, 1.5]; stronger association with peptic ulcer, site unspecified [SIR: 3.3, 95% CI: 1.8, 5.5]). Stratified analyses revealed that some associations were stronger for persons ages 16-39 or unmarried at PTSD diagnosis, persons with comorbid psychiatric diagnoses, and in the year following PTSD diagnosis.

CONCLUSIONS

This study documents associations between clinician-diagnosed PTSD and all major nonmalignant GI disorders in an unselected nationwide cohort with long follow-up. Differences in associations across GI disorders and important modifiers may account for previous conflicting research findings.

Posttraumatic Stress Disorder 23 Years After the 1988 Spitak Earthquake in Armenia

This population-based longitudinal study examined the rates and predictors of posttraumatic stress disorder (PTSD) among 725 differentially exposed survivors of the 1988 Spitak earthquake in Armenia, 23 years after the event. Participants had been previously evaluated in 1991. Evaluations included assessment of current PTSD (based on DSM-5 criteria), and a variety of potential risk and protective factors. For the whole sample, the rate of PTSD attributed to the earthquake decreased from 48.7% in 1991 to 11.6% in 2012 (p < .001). A "dose of exposure" pattern persisted, and 15.7% of participants who were in Spitak (high exposure) and 6.6% of participants who were in Kirovagan (low exposure) during the earthquake met the criteria for PTSD (p = .003). Additionally, in 2012, another 9.9% of participants met PTSD criteria due to post-earthquake traumas, which is a 5-fold increase from pre- to postearthquake (p < . 001). Factors positively associated with PTSD included earthquake-related job loss, exposure to post-earthquake traumas, depression at baseline, and chronic illness since the earthquake. Factors inversely associated with PTSD included housing assistance within two years after the earthquake, support of family and/or friends, and to a lesser degree, higher education and high living standard. These variables accounted for 23.1% of the variance in current PTSD severity scores. These findings indicate that PTSD rates subside significantly after a catastrophic disaster, although earthquake-related PTSD persists among a subgroup of exposed individuals. Predictors of PTSD identified in this study provide guidance for planning acute and longer-term postdisaster public mental health recovery programs.

Insomnia in United States military veterans: An integrated theoretical model

Marked by difficulty falling or staying asleep and/or poor sleep leading to daytime dysfunction, insomnia contributes to functional impairment, poor health, and increased healthcare utilization when left untreated. As many as two-thirds of Iraq and Afghanistan military veterans complain of insomnia. Older veterans of prior conflicts report insomnia occurring since initial service, suggesting a chronic nature to insomnia in this population. Despite insomnia's high prevalence and severe consequences, there is no theoretical model to explain either the onset or chronicity of insomnia in this growing patient population. Existing theories view insomnia as an acute, unidirectional phenomenon and do little to elucidate long-term consequences of such problems. Existing theories also fail to address mechanisms by which acute insomnia becomes chronic. This paper presents an original, integrated theoretical model that draws upon constructs from several prominent behavioral medicine theories to reconceptualize insomnia as a chronic, cyclical problem that is both a consequence and predictor of stress. Additional research examining the relationships between stress, sleep, resilience, and outcomes of interest could inform clinical and research practices. Addressing sleep problems early could potentially enhance adaptive capacity, thereby reducing the risk for subsequent negative outcomes.

Prospective Examination of Early Associations of Iraq War Zone Deployment, Combat Severity, and Posttraumatic Stress Disorder with New Incident Medical Diagnoses

War zone deployment and posttraumatic stress disorder (PTSD) have been associated with morbidity and mortality decades later. Less is known about the associations between these variables and the early emergence of medical disorders in war zone veterans. This prospective study of 862 U.S. Army soldiers (n = 569 deployed; n = 293 nondeployed) examined: (a) associations between Iraq War deployment status (deployed vs. nondeployed) and new medical diagnoses that emerged within six months after return from Iraq among all participants; and (b) associations between combat severity and PTSD symptoms, and new postdeployment medical diagnoses that emerged within 12 months after return from Iraq within deployed participants. New medical diagnoses were abstracted from diagnostic codes associated with clinical outpatient visits recorded within the Department of Defense Standard Ambulatory Data Record database. Combat severity was measured with the Combat Experiences module of the Deployment Risk and Resilience Inventory, and postdeployment posttraumatic stress disorder symptom severity was measured using the PTSD Checklist-Civilian. Neither deployment nor combat severity was associated with new medical diagnoses. However, among deployed soldiers, more severe PTSD symptoms were associated with increased risk for a new medical disorder diagnosis; every 10-point increase in PTSD symptoms increased odds of a new diagnosis by nearly 20% (odds ratio = 1.20). Results suggest that PTSD symptoms are associated with early morbidity in Iraq War veterans.

Accelerated DNA Methylation Age: Associations With Posttraumatic Stress Disorder and Mortality

OBJECTIVE

Recently developed indices of cellular age based on DNA methylation (DNAm) data, referred to as DNAm age, are being used to study factors that influence the rate of aging and the health correlates of these metrics of the epigenetic clock. This study evaluated associations between trauma exposure, posttraumatic stress disorder (PTSD) symptoms, and accelerated versus decelerated DNAm age among military veterans. We also examined whether accelerated DNAm age predicted mortality over the course of a 6.5-year medical record review period.

METHODS

Three hundred thirty-nine genotype-confirmed white, non-Hispanic, middle-aged, trauma-exposed veterans underwent psychiatric assessment and genome-wide DNAm analysis. DNAm age was calculated using a previously validated algorithm. Medical records were available for a subset of 241 veterans and were reviewed approximately 6.5 years after DNA collection and PTSD assessment.

RESULTS

PTSD hyperarousal symptoms were associated with accelerated DNAm age (β = 0.20, p = .009) but trauma exposure and total PTSD severity were not. Accelerated DNAm age was also associated with 13% increased risk for all-cause mortality (hazard ratio = 1.13, 95% confidence interval = 1.01-1.26) during the medical record review period.

CONCLUSIONS

Findings of this study replicate the association between PTSD and accelerated DNAm age and suggest that this effect may be specific to the hyperarousal symptom cluster. Results point to the potential utility of DNAm age algorithms for identifying individuals who are aging at an accelerated rate and for determining the factors that influence this process.

Posttraumatic Stress Disorder and Somatic Complaints in a Deployed Cohort of Georgian Military Personnel: Mediating Effect of Depression and Anxiety

Several studies have shown the relationship between symptoms of posttraumatic stress disorder (PTSD), somatic symptoms, and the mediating effect of depression and anxiety. The following study was conducted to investigate the relationship between PTSD symptoms and somatic complaints through underlying symptoms of depression and anxiety. The participants of the study were 2,799 veterans who were examined after a 6-month deployment. They were assessed using the PTSD Checklist (PCL-5) and Patient Health Questionnaire (PHQ) for depression, anxiety, and somatic complaints. To check the indirect effect of PTSD on somatic complaints through depression and anxiety, mediation model 4 (parallel mediation) of the SPSS PROCESS macro was used. There was a significant total indirect effect of PTSD through depression and anxiety on somatic complaints, b = 0.14, 95% confidence interval (CI) [0.12, 0.16], from which an indirect effect of PTSD on somatic complaints through depression was b = 0.08, 95% CI [0.06, 0.10], and through anxiety it equaled b = 0.06, 95% CI [0.04, 0.07]. The ratio of indirect to total effect was 0.66, 95% CI [0.59, 0.75]. The present study helps us to understand the role of depression and anxiety symptoms when the symptoms of PTSD and somatic complaints are present. These new findings may have implications for the management as well as treatment of PTSD because they recognize the importance of symptoms of anxiety and depression when somatic complaints are present.

Physical and Mental Health Consequences of War-related Stressors Among Older Adults: An Analysis of Posttraumatic Stress Disorder and Arthritis in Northern Vietnamese War Survivors

Objectives

We examine the impacts of trauma exposures and family stressors associated with the Vietnam War on musculoskeletal health and posttraumatic stress disorder (PTSD) outcomes in elderly Vietnamese who were widely impacted by the war as young adults. Noting that wars' impacts extend beyond male veterans in most survivor populations, we give attention to male and female war survivors placed in a variety of roles vis-a-vis the war.

Method

Utilizing data from the 2010 Vietnam Health and Aging Pilot Study (N = 405), we use logistic and Poisson regression models to estimate the effect of wartime trauma exposures and family stressors on disabling arthritis and PTSD symptoms in male and female northern Vietnamese adults aged 55 and older.

Results

The odds of experiencing recent PTSD symptoms are greater in respondents who report involvement in killing/causing severe injury and who observed war atrocities. In women, PTSD is positively correlated with war era child death and spousal separation. Arthritis also exhibits a significant, positive association with killing/causing severe injury.

Discussion

Our study provides insights into the burden of conflict upon health among populations of the global south that survived war and are now entering older adulthood. The pattern of results, indicating greatest suffering among those who inflicted or failed to prevent bodily harm or loss of life, is consistent with the concept of moral injury.

Effects of trauma and PTSD on self-reported physical functioning in sexual minority women

OBJECTIVE

Sexual minority women (lesbians, bisexual women, and women who partner with women) experience high rates of trauma exposure, are more likely to develop posttraumatic stress disorder (PTSD), and have high rates of physical health problems compared with heterosexual women. The present study tested whether PTSD may be the mechanism through which trauma exposure affects self-reported physical functioning in this population.

METHOD

In a sample of 857 sexual minority women, we examined the association between trauma exposure and worsening physical functioning (measured using the 12-item Short Form Health Survey) 2 years later, whether PTSD mediated this relationship, and if so, which PTSD symptom clusters best accounted for this mediation.

RESULTS

Results showed that more Criterion A traumatic events experienced (based on DSM-IV) predicted greater decline in physical functioning 2 years later, and PTSD symptoms mediated this relationship, explaining 73% of the total effect. The arousal/reactivity symptom cluster was the only significant mediator, explaining 68% of the total effect.

CONCLUSIONS

Results show that PTSD, and arousal/reactivity symptoms in particular, may be the mechanism through which traumatic events negatively impact self-reported physical functioning. These findings provide further evidence that, for this at risk population, treating PTSD as soon as possible after onset may improve long term physical functioning. (PsycINFO Database Record

Prevalence and prognosis of stress disorders: a review of the epidemiologic literature

Given the ubiquity of traumatic events, it is not surprising that posttraumatic stress disorder (PTSD) - a common diagnosis following one of these experiences - is characterized as conferring a large burden for individuals and society. Although there is recognition of the importance of PTSD diagnoses throughout psychiatry, the literature on other diagnoses one may receive following a stressful or traumatic event is scant. This review summarizes the literature on stress disorders (classified according to the International Classification of Diseases, 10th Edition [ICD-10]), including acute stress reaction, PTSD, adjustment disorder and unspecified stress reactions. This review focuses on the literature related to common psychiatric and somatic consequences of these disorders. The prevalence and incidence of each disorder are described. A review of epidemiologic studies on comorbid mental health conditions, including depression, anxiety and substance abuse, is included, as well as a review of epidemiologic studies on somatic outcomes, including cancer, cardiovascular disease and gastrointestinal disorders. Finally, the current literature on all-cause mortality and suicide following stress disorder diagnoses is reviewed. Stress disorders are a critical public health issue with potentially deleterious outcomes that have a significant impact on those living with these disorders, the health care system and society. It is only through an awareness of the impact of stress disorders that appropriate resources can be allocated to prevention and treatment. Future research should expand the work done to date beyond the examination of PTSD, so that the field may obtain a more complete picture of the impact all stress disorders have on the many people living with these diagnoses.

Evidence-based Treatments for Military-related Posttraumatic Stress Disorder in a Veterans Affairs Setting

Posttraumatic stress disorder (PTSD) can have a significant negative impact on the physical, emotional, and mental health of individuals. This article discusses the prevalence, risk factors, and diagnostic criteria for PTSD. Given the high incidence of PTSD in the Veteran population, much attention has been given to assessment and treatment issues. Treatment options for PTSD, including the 2 most effective treatments, prolonged exposure and cognitive processing therapy, are discussed. Special issues concerning the treatment of Veterans are also reviewed.

Combat exposure, social relationships, and subjective well-being among middle-aged and older Veterans

OBJECTIVES

This study described the association of subjective well-being with combat exposure and social relationships among middle-aged and older Veteran men in the USA. The stress-buffering hypothesis, which predicts social relationships may moderate the association between combat exposure and subjective well-being, was also examined.

METHOD

Data from the 2008 Health and Retirement Study (N = 2961) were used to estimate logistic regression models, focusing on three measures of subjective well-being: depression, life satisfaction, and self-reported health.

RESULTS

In the fully adjusted models, there were no statistically significant relationships between combat exposure and the three indicators of subjective well-being. However, compared to Veterans who had lower scores on the social relationship index, Veterans who had higher scores were less likely to be depressed and less likely to report poor or fair health. Veterans who had higher scores on the social relationships index reported higher levels of life satisfaction than those Veterans who had lower scores. There was no evidence for a social relationships buffering effect.

CONCLUSION

The results of this study demonstrated that combat exposure did not have a long-term relationship with subjective well-being. Longitudinal research designs with more comprehensive indicators of combat exposure may help researchers better understand some of the underlying complexity of this relationship. Complementary research with samples of women Veterans, as well as samples of Hispanic, and non-Black, non-White Veterans, is also needed.

Posttraumatic Stress Disorder Among Older Patients with Chronic Obstructive Pulmonary Disease

This study explored (1) the incidence of posttraumatic stress disorder (PTSD) resulting from past trauma among older patients with COPD and (2) whether PTSD and COPD severity would relate to psychiatric co-morbidity and health-related quality of life. Eighty-five older patients completed the Hospital Anxiety and Depression Scale, the Chronic Respiratory Questionnaire, the Posttraumatic Stress Diagnostic Scale and the Medical Outcomes Short Form 12. The results showed that 55, 39 and 6 % had no, partial and full-PTSD respectively. Partial least squares showed that PTSD was significantly correlated with COPD severity which in turn was significantly correlated with health-related quality of life and psychiatric co-morbidity. Mediational analysis showed that the emotional symptoms of COPD mediated between PTSD and the mental health functioning of health-related quality of life and between PTSD and depression. To conclude, PTSD from past trauma was related to the severity of COPD for older patients. In particular, it impacted on the elevated emotional arousal of COPD severity. In turn, COPD severity impacted on older patients' general psychological well-being and depression.

Post-traumatic stress disorder symptoms and risk of hypertension over 22 years in a large cohort of younger and middle-aged women

BACKGROUND

Post-traumatic stress disorder (PTSD) has been linked to hypertension, but most research on PTSD and hypertension is cross-sectional, and potential mediators have not been clearly identified. Moreover, PTSD is twice as common in women as in men, but understanding of the PTSD-hypertension relationship in women is limited. We examined trauma exposure and PTSD symptoms in relation to incident hypertension over 22 years in 47 514 civilian women in the Nurses' Health Study II.

METHOD

We used proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for new-onset hypertension (N = 15 837).

RESULTS

PTSD symptoms assessed with a screen were modestly associated with incident hypertension in a dose-response fashion after adjusting for potential confounders. Compared to women with no trauma exposure, women with 6-7 PTSD symptoms had the highest risk of developing hypertension (HR 1.20, 95% CI 1.12-1.30), followed by women with 4-5 symptoms (HR 1.17, 95% CI 1.10-1.25), women with 1-3 symptoms (HR 1.12, 95% CI 1.06-1.18), and trauma-exposed women with no symptoms (HR 1.04, 95% CI 1.00-1.09). Findings were maintained, although attenuated, adjusting for hypertension-relevant medications, medical risk factors, and health behaviors. Higher body mass index and antidepressant use accounted for 30% and 21% of the PTSD symptom-hypertension association, respectively.

CONCLUSIONS

Screening for hypertension and reducing unhealthy lifestyle factors, particularly obesity, in women with PTSD may hold promise for offsetting cardiovascular risk.

Cortisol, heart rate, and blood pressure as early markers of PTSD risk: A systematic review and meta-analysis

Individuals with posttraumatic stress disorder (PTSD) typically exhibit altered hypothalamic-pituitary-adrenal (HPA) function and sympathetic nervous system (SNS) activity. The goals of this study were to determine whether HPA and SNS alterations in the immediate aftermath of trauma predict subsequent PTSD symptom development and whether inconsistencies observed between studies can be explained by key demographic and methodological factors. This work informs secondary prevention of PTSD by identifying subgroups of trauma survivors at risk for PTSD. This meta-analysis (26 studies, N=5186 individuals) revealed that higher heart rate measured soon after trauma exposure was associated with higher PTSD symptoms subsequently (r=0.13). Neither cortisol (r=-0.07) nor blood pressure (diastolic: r=-0.01; systolic: r=0.02) were associated with PTSD symptoms which may be influenced by methodological limitations. Associations between risk markers (heart rate, cortisol, systolic blood pressure) and PTSD symptoms were in the positive direction for younger samples and negative direction for older samples. These findings extend developmental traumatology models of PTSD by revealing an age-related shift in the presentation of early risk markers. More work will be needed to identify risk markers and pathways to PTSD while addressing methodological limitations in order to shape and target preventive interventions.

The long-term impact of combat exposure on health, interpersonal, and economic domains of functioning

PURPOSE

Wartime combat exposure is linked to a broad array of negative outcomes. The current study identified potential differences between middle-to-older aged men exposed to combat and those not exposed for physical health, interpersonal, and economic functioning over 10 years. Post-traumatic stress disorder (PTSD) and social support were examined as moderators between combat exposure and outcomes.

METHODS

Data from the National Comorbidity Survey, baseline and 10-year follow-up, were utilized. Only men aged 50-65 at follow-up (N = 727) were included. Group differences between combat and non-combat men were examined. Regression analyses were performed to examine relationships between earlier combat and health, interpersonal, and economic outcomes over time, while controlling for important covariates.

RESULTS

Combat-exposed men were at increased risk for asthma, arthritis/rheumatism, lung diseases, headaches, and pain; they also had greater marital instability. However, combat-exposed men reported economic advantages, including higher personal earnings at follow-up. For combat-exposed men, PTSD did not increase risk for headaches; however, PTSD in non-combat men was associated with increased risk for headaches at follow-up. Whereas combat-exposed men with higher levels of social support were less likely to report chronic pain at follow-up, there were no group differences in pain at lower levels of social support.

IMPLICATIONS

Individuals who experience combat may be susceptible to later health and marital problems; however, as combat-exposed men age, they demonstrate some resilience, including in economic domains of life. Given that consequences of combat may manifest years after initial exposure, knowledge of combat exposure is necessary to inform treatments and the delivery of disability benefits.

Physical Activity Counseling Promotes Physical and Psychological Resilience in Older Veterans with Posttraumatic Stress Disorder

Individuals with posttraumatic stress disorder (PTSD) have elevated rates of morbidity, and a sedentary lifestyle can cause and aggravate the physical health needs of adults with PTSD. The primary aim of this paper was to explore the impact of physical activity (PA) counseling (vs. usual care) on physical and psychological outcomes among individuals with PTSD. A secondary aim was to compare these arm effects between those with and without PTSD.

METHODS

Older (>60 years) overweight veterans with impaired glucose tolerance were randomly assigned to an intervention or a usual care control arm. Of the 302 participants who underwent randomization, 67 (22%) had PTSD. Participants in the intervention arm received one in-person activity counseling session followed by regular PA telephone counseling over 12 months. Physical and psychological outcomes were assessed at baseline, 3, and 12 months.

RESULTS

Primary Aim (intervention vs. usual care among those with PTSD): PA increased on average from 80 minutes/week to 161 minutes/week among participants in the intervention arm (p=0.01). Large, clinically meaningful improvements in six-minute walk test and psychological health were observed over the course of the intervention (p<0.01). Secondary Aim (PTSD/No PTSD, intervention/usual care): participants with PTSD responded equally well to the intervention compared to participants without PTSD, though we observed significantly greater improvements in vitality and six-minute walk compared to participants without PTSD (p<0.05).

CONCLUSIONS

Given the epidemic of comorbid psychological illness and lifestyle-related disease among persons with PTSD, our findings support development and implementation of targeted PA interventions in this high-risk population.

Trauma and PTSD in older adults: Prevalence, course, concomitants and clinical considerations

This review presents recent empirical developments on Posttraumatic Stress Disorder (PTSD) in older adults, highlighting some of the most interesting lines of investigation that have taken place over the past few years. The majority of the extant literature has focused on male veterans or former prisoners of war, Caucasians, and those from the United States. Major advances have taken place in terms longitudinal investigations of representative samples of veterans and their health and functioning in relation to traumatic exposure. The current review explores the prevalence and impact, course and associated consequences, as well as available treatment for older adult survivors of traumatic experiences in an effort to increase education and awareness to improve overall health and functioning among this population.

When Nations Call

Most scholarship on aging is based on cohorts born early in the 20th century, and these cohorts have had significant experience with war. Wartime experiences may therefore be critical but largely hidden variables underlying current scientific knowledge about aging. Evidence marshaled in this article illustrates the powerful insights gained when research on this topic is guided by lifecourse propositions and data. It reveals how wartime military service, especially during World War II, affected the short- and long-ranging development of recruits. It also highlights the need to better account for the potential legacies of service for physical, psychological, and social functioning in late life. These matters will become increasingly important as sizable World War II and Korean veteran populations move through advanced old age, and as the Vietnam veteran population moves into old age. Systematic attention to the effects of wartime service is necessary to determine the degree to which contemporary knowledge about aging can be generalized to future cohorts.

Rates and consequences of posttraumatic distress among American Indian adults with type 2 diabetes

This study examined the prevalence of screened posttraumatic stress disorder (PTSD) and associated diabetes-related outcomes. A sample of American Indian adults with type 2 diabetes (n = 218) participated in interviewer-administered surveys. Using a cutoff of 3 on the Primary Care PTSD screener, 21.8 % of participants screened positive for PTSD. PTSD symptoms were negatively associated with self-rated health status and positively associated with past year hospitalization after controlling for several demographic factors, but not after controlling for depressive symptoms. Past month frequency of hyperglycemia symptoms was not related to PTSD symptoms. When grouped by mental health conditions (neither screened PTSD nor depressive symptoms, screened PTSD only, depressive symptoms only, and both), those with both screened PTSD and depressive symptoms reported the highest proportion of any past month hyperglycemia, past year hospitalization, and low self-rated health status. Screened PTSD, especially in those with comorbid depressive symptoms, is an important consideration in diabetes care.

Posttraumatic Stress Disorder, Overweight, and Obesity: A Systematic Review and Meta-analysis

Previous reports have suggested a high prevalence of overweight and obesity among individuals with posttraumatic stress disorder (PTSD). Few studies, however, systematically analyze the relationship between PTSD and body mass index (BMI). We conducted a systematic review and meta-analysis aimed at estimating the association between PTSD and BMI. Fifty-four articles were reviewed, 30 of which (with 191,948 individuals with PTSD and 418,690 trauma-exposed individuals or healthy controls) were eligible for inclusion in the meta-analysis. The pooled standard mean difference, based on a random-effects model, was 0.41 (95% confidence interval, 0.28-0.54; z = 6.26; p < .001). Statistical heterogeneity between the included studies was high (p < .001; I = 99%). Despite limitations, the findings of this systematic review and meta-analysis suggest an association between PTSD and BMI. Furthermore, longitudinal studies tentatively indicate that PTSD may lead to an increase in BMI and, as such, to the development of overweight/obesity, particularly in women. Further prospective studies and research elaborating the nature and etiology of the association are required.

Longitudinal associations between post-traumatic stress disorder and metabolic syndrome severity

BACKGROUND

Post-traumatic stress disorder (PTSD) is associated with elevated risk for metabolic syndrome (MetS). However, the direction of this association is not yet established, as most prior studies employed cross-sectional designs. The primary goal of this study was to evaluate bidirectional associations between PTSD and MetS using a longitudinal design.

METHOD

A total of 1355 male and female veterans of the conflicts in Iraq and Afghanistan underwent PTSD diagnostic assessments and their biometric profiles pertaining to MetS were extracted from the electronic medical record at two time points (spanning ~2.5 years, n = 971 at time 2).

RESULTS

The prevalence of MetS among veterans with PTSD was just under 40% at both time points and was significantly greater than that for veterans without PTSD; the prevalence of MetS among those with PTSD was also elevated relative to age-matched population estimates. Cross-lagged panel models revealed that PTSD severity predicted subsequent increases in MetS severity (β = 0.08, p = 0.002), after controlling for initial MetS severity, but MetS did not predict later PTSD symptoms. Logistic regression results suggested that for every 10 PTSD symptoms endorsed at time 1, the odds of a subsequent MetS diagnosis increased by 56%.

CONCLUSIONS

Results highlight the substantial cardiometabolic concerns of young veterans with PTSD and raise the possibility that PTSD may predispose individuals to accelerated aging, in part, manifested clinically as MetS. This demonstrates the need to identify those with PTSD at greatest risk for MetS and to develop interventions that improve both conditions.

The evolution of the molecular response to stress and its relevance to trauma and stressor-related disorders

The experience of "stress", in its broadest meaning, is an inevitable part of life. All living creatures have evolved multiple mechanisms to deal with such threats and challenges and to avoid damage to the organism that may be incurred from these stress responses. Trauma and stressor-related disorders are psychiatric conditions that are caused specifically by the experience of stress, though depression, anxiety and some other disorders may also be unleashed by stress. Stress, however, is not a mandatory criterion of these diagnoses. This article focuses on the evolution of the neurochemicals involved in the response to stress and the systems in which they function. This includes the skin and gut, and the immune system. Evidence suggests that responses to stress are evolutionarily highly conserved, have wider involvement than the hypothalamic pituitary adrenal stress axis alone, and that excessive stress responses can produce stressor-related disorders in both humans and animals.

Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: a Randomized Controlled Trial

BACKGROUND

The effectiveness of collaborative care of mental health problems is clear for depression and growing but mixed for anxiety disorders, including posttraumatic stress disorder (PTSD). We know little about whether collaborative care can be effective in settings that serve low-income patients such as Federally Qualified Health Centers (FQHCs).

OBJECTIVE

We compared the effectiveness of minimally enhanced usual care (MEU) versus collaborative care for PTSD with a care manager (PCM).

DESIGN

This was a multi-site patient randomized controlled trial of PTSD care improvement over 1 year.

PARTICIPANTS

We recruited and enrolled 404 patients in six FQHCs from June 2010 to October 2012. Patients were eligible if they had a primary care appointment, no obvious physical or cognitive obstacles to participation, were age 18-65 years, planned to continue care at the study location for 1 year, and met criteria for a past month diagnosis of PTSD.

MAIN MEASURES

The main outcomes were PTSD diagnosis and symptom severity (range, 0-136) based on the Clinician-Administered PTSD Scale (CAPS). Secondary outcomes were medication and counseling for mental health problems, and health-related quality of life assessed at baseline, 6 months, and 12 months.

KEY RESULTS

Patients in both conditions improved similarly over the 1-year evaluation period. At 12 months, PTSD diagnoses had an absolute decrease of 56.7% for PCM patients and 60.6% for MEU patients. PTSD symptoms decreased by 26.8 and 24.2 points, respectively. MEU and PCM patients also did not differ in process of care outcomes or health-related quality of life. Patients who actually engaged in care management had mental health care visits that were 14% higher (p < 0.01) and mental health medication prescription rates that were 15.2% higher (p < 0.01) than patients with no engagement.

CONCLUSIONS

A minimally enhanced usual care intervention was similarly effective as collaborative care for patients in FQHCs.

PTSD and Risk of Incident Cardiovascular Disease in Aging Veterans

OBJECTIVES

To determine if late-life posttraumatic stress disorder (PTSD) is associated with cardiovascular disease in a sample of older veterans, and whether the association is independent of medical and psychiatric comorbities.

DESIGN

Retrospective cohort study conducted using the Department of Veterans Affairs (VA) National Patient Care Database (2000-2011).

SETTING

VA medical centers in the United States.

PARTICIPANTS

A total of 138,341 veterans 55 years and older without cardiovascular disease at study baseline (2000-2003).

MEASUREMENTS

PTSD and cardiovascular disease (as defined by diagnoses of: cerebrovascular disease [CVD], congestive heart failure [CHF], myocardial infarction [MI], and peripheral vascular disease [PVD]) were identified by ICD-9 codes during study baseline (2000-2003) and follow-up (2004-2011), respectively.

RESULTS

3% of veterans (N = 4,041) had a baseline diagnosis of PTSD. Unadjusted increased risk of incidence of CVD was 80%, CHF was 56%, MI was 82%, and PVD was 60% in veterans with PTSD compared with those without PTSD. After adjustment for demographics, medical comorbidities, substance use, and psychiatric comorbidities, veterans with late-life PTSD were at a 45% increased risk for incident CVD, 26% increased risk for incident CHF, 49% increased risk for incident MI, and 35% increased risk for PVD compared with veterans without late-life PTSD.

CONCLUSIONS

Findings highlight the longitudinal impact of PTSD on increasing the incidence of cardiovascular disease in older adults. This study implies the need for greater monitoring and treatment of PTSD in older persons, particularly older veterans, to assist in preventing adverse outcomes, such as cardiovascular disease, over the long term.