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Breneman CB, Valmas MM, Skalina LM, Cypel Y, Spiro A, Frayne SM, Magruder KM, Kilbourne AM, Kimerling R, Reinhard MJ. Mental Health and Cognition in Women Veterans Enrolled in the Health of Vietnam Era Veteran Women's Study (HealthViEWS). J Womens Health (Larchmt) 2024. [PMID: 38913339 DOI: 10.1089/jwh.2023.0974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
Objective: This analysis explored relationships between mental health symptoms and conditions and cognitive function in a cohort of Vietnam-era women veterans from the Health of Vietnam Era Veteran Women's Study (HealthViEWS). Methods: Vietnam-era women veterans completed a mail survey assessing self-reported symptom severity of posttraumatic stress disorder (PTSD) and depression. A telephone-based structured interview assessed mental health conditions and cognitive function (telephone interview for cognitive status [TICS]). Participants were categorized using a TICS threshold of ≤29 to designate possible cognitive impairment versus nonimpaired. Separate logistic regression models were used to determine associations between possible cognitive impairment and each self-reported and interviewer-rated assessment of PTSD and depression while adjusting for age, education, race, marital status, and wartime service location. Results: The sample consisted of 4,077 women veterans who were ≥60 years old and completed the TICS. Of these women, 7.20% were categorized with possible cognitive impairment. Logistic regression models indicated that self-reported PTSD and depression symptom severity were each significantly associated with higher odds of possible cognitive impairment (adjusted odds ratios [aOR]: 1.03 [95% confidence interval [CI]: 1.02-1.04] and 1.07 [95% CI: 1.04-1.09], respectively). Women veterans with a probable diagnosis of depression had higher odds of possible cognitive impairment compared to those without depression (aOR: 1.61 [95% CI: 1.07-2.42]). No association was found for probable diagnosis of PTSD. Conclusions: Although further examination remains necessary, results suggest that Vietnam-era women veterans with self-reported PTSD and depression symptom severity or a probable diagnosis of depression may benefit from screening of cognitive function to inform clinical care.
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Affiliation(s)
- Charity B Breneman
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland, USA
- Department of Veterans Affairs, War Related Illness and Injury Study Center (WRIISC), Washington, District of Columbia, USA
| | - Mary M Valmas
- Department of Veterans Affairs, War Related Illness and Injury Study Center (WRIISC), Washington, District of Columbia, USA
- Department of Veterans Affairs, Washington DC VA Medical Center, Washington, District of Columbia, USA
| | - Lauren M Skalina
- Department of Veterans Affairs, Washington DC VA Medical Center, Washington, District of Columbia, USA
| | - Yasmin Cypel
- Department of Veterans Affairs, Health Outcomes Military Exposures, Veterans Health Administration, Washington, District of Columbia, USA
| | - Avron Spiro
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts, USA
- Departments of Epidemiology and Psychiatry, Boston University Schools of Public Health and Medicine, Boston, Massachusetts, USA
| | - Susan M Frayne
- National Center for PTSD and VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, California, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kathryn M Magruder
- Departments of Psychiatry and Behavioral Sciences and Public Health, Medical University of SC, Charleston, South Carolina, USA
| | - Amy M Kilbourne
- US Department of Veterans Affairs, Quality Enhancement Research Initiative (QUERI), Washington, District of Columbia, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Rachel Kimerling
- National Center for PTSD and VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Matthew J Reinhard
- Department of Veterans Affairs, War Related Illness and Injury Study Center (WRIISC), Washington, District of Columbia, USA
- Department of Psychiatry, Georgetown University Medical Center, Washington, District of Columbia, USA
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2
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Ebrahimi R, Yano EM, Alvarez CA, Dennis PA, Shroyer AL, Beckham JC, Sumner JA. Trends in Cardiovascular Disease Mortality in US Women Veterans vs Civilians. JAMA Netw Open 2023; 6:e2340242. [PMID: 37902755 PMCID: PMC10616720 DOI: 10.1001/jamanetworkopen.2023.40242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/17/2023] [Indexed: 10/31/2023] Open
Abstract
Importance Cardiovascular disease (CVD) remains the leading cause of death in the US. Women veterans have higher rates of CVD compared with civilian US women; however, analyses of recent trends in mortality from cardiac disease for women veterans are lacking. Objective To investigate trends in cardiac disease mortality among women veterans over approximately the past 2 decades and compare rates with those for civilian women. Design, Setting, and Participants In this retrospective longitudinal cohort study, US Veterans Health Administration (VHA) electronic health record data, linked with the National Death Index, were analyzed for CVD trends and rates of cardiac disease mortality among women veterans (aged 18 years or older) with VHA health care encounters from January 1, 2000, to December 31, 2017. These data were compared with a national cohort of civilian women (aged 15 years or older) in the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database, which provides cause-of-death data using death certificates for all US residents. The data analysis was performed between March 10, 2021, and November 28, 2022. Exposure Cardiac disease mortality among women veterans and civilian women. Main Outcomes and Measures Cardiac disease mortality was based on International Classification of Diseases, Tenth Revision diagnostic codes (I00-I09, I11, I13, and I20-I51 as defined by CDC WONDER). For women veterans and civilian women, crude and age-adjusted cardiac disease mortality rates (per 100 000 life-years) and 95% CIs were calculated, with the 2000 US general population as the reference for age-adjusted rates. Results From 2000 to 2017, 817 912 women veterans engaged with VHA health care (mean [SD] age, 45.7 [17.1] years), and 19 022 cardiac disease deaths were identified (22.4% of total deaths). The crude and age-adjusted cardiac disease mortality rates, respectively, per 100 000 life-years were 200.2 (95% CI, 181.0-221.0) and 197.6 (95% CI, 175.2-222.0) in 2000 and 196.0 (95% CI, 186.1-206.4) and 208.1 (95% CI, 196.4-220.4) in 2017, reflecting stable crude rates and a 5.3% increase in age-adjusted rates. For civilian women, the crude and age-adjusted rates decreased over time from 320.7 (95% CI, 319.7-321.8) and 268.1 (95% CI, 267.3-269.0) in 2000 to 220.9 (95% CI, 220.1-221.7) and 164.7 (95% CI, 164.1-165.3) in 2017. Conclusions and Relevance In this cohort study comparing women veterans and civilian women, cardiac disease mortality rates for women veterans did not exhibit the improvements seen for civilian women during the nearly 2-decade study period. Further research and actionable clinical interventions are warranted to improve cardiovascular care for women veterans, who represent the fastest growing group of patients within the VHA health care system.
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Affiliation(s)
- Ramin Ebrahimi
- Department of Medicine, University of California, Los Angeles
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Elizabeth M. Yano
- Veterans Affairs Health Services Research & Development Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Health Policy and Management, University of California Los Angeles
| | - Carlos A. Alvarez
- Department of Pharmacy Practice, Texas Tech University Health Science Center, Dallas
- Department of Research, Veterans Affairs North Texas Health Care System, Dallas
| | - Paul A. Dennis
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - A. Laurie Shroyer
- Department of Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
- Northport Veterans Affairs Medical Center, Northport, New York
| | - Jean C. Beckham
- Durham Veterans Affairs Medical Center, Durham, North Carolina
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
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Sullivan-Baca E, Rehman R, Haneef Z. An Update on the Healthy Soldier Effect in U.S. Veterans. Mil Med 2023; 188:3199-3204. [PMID: 35652579 DOI: 10.1093/milmed/usac151] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/20/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The healthy soldier effect (HSE) describes a phenomenon of enduring health and lower mortality among veterans due in part to initial screening procedures and health care access. Although early data were supportive of a broad HSE among former military members, more recent investigations have suggested a possible attenuation of the effect with older age. The present study aimed to provide an update of the HSE using an expansive Veterans Health Administration (VHA)-wide sample with a particular focus on age and sex effects. MATERIALS AND METHODS Mortality data for veterans within the VHA were obtained from the VHA Support Service Center program office and compared to mortality data from the general U.S. population spanning FY2014 to the second quarter of FY2020. The standardized mortality ratio (SMR) was calculated for the overall sample and for age- and sex-specific cohorts. Mortality rate ratios were also calculated and compared across sexes. RESULTS Lower SMRs were observed in veterans compared to the general U.S. population (SMR 0.866). This effect was most prominent in younger and very old veterans, although a higher mortality was seen in the 55- to 64-year age cohort (SMR 1.371 for males and 1.074 for females). The HSE in females was lower than that in males in the <55-year age group but became higher in older cohorts. CONCLUSIONS This is the largest investigation to date examining the HSE in U.S. veterans and includes younger veterans from more recent military eras. Higher mortality among the 55- to 74-year age groups merits further investigation, as does the relatively higher mortality among older female veterans. Our findings have implications for the provision of health care and preventative care to these veterans most at risk for higher mortality.
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Affiliation(s)
| | - Rizwana Rehman
- Epilepsy Centers of Excellence, Durham VA Medical Center, Durham, NC 27705, USA
| | - Zulfi Haneef
- Neurology Care Line, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
- Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
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Weitlauf JC, Cypel YS, Davey VJ. Mortality of Women Vietnam War-Era Veterans. Womens Health Issues 2023:S1049-3867(23)00068-3. [PMID: 37088602 DOI: 10.1016/j.whi.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 02/07/2023] [Accepted: 02/24/2023] [Indexed: 04/25/2023]
Abstract
PURPOSE Our objectives were to 1) understand the scope of the current mortality literature on U.S. women Vietnam War-era veterans and 2) identify major themes and knowledge gaps that might guide future research. METHODS A systematic scoping review was conducted. Electronic bibliographic databases were searched for studies published on women Vietnam War-era veterans' mortality between 1973 and 2020. Inclusion and exclusion criteria were applied, study information was charted using pre-established design parameters, and studies deemed eligible were retained for a more in-depth review. FINDINGS One hundred nineteen studies were initially identified. Of these, six were ultimately retained for critical review. External cause, all-cause, cancer, and cardiovascular mortality were prominent outcomes across studies. Although both methodology and outcomes varied by study, unifying themes emerged. Prominent themes included a) historic barriers to accurately identifying and classifying this veteran cohort, b) historic barriers to comprehensive assessment of their health and mortality risk, and c) the healthy soldier effect and its limitations. Research gaps identified in this review reflect a need to pay more attention to sex differences in mortality risk and military occupational and sex-specific health risk confounders in mortality models. CONCLUSIONS The research literature examining mortality among women Vietnam War-era veterans is circumscribed in size and scope. Questions about the roles of salient military occupational exposures and health risk factors on mortality risks and trends in this cohort remain unaddressed. These questions should be areas of focus in next steps research.
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Affiliation(s)
- Julie C Weitlauf
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, Stanford, California.
| | - Yasmin S Cypel
- Epidemiology Program, Post Deployment Health Service (12POP5), Office of Patient Care Services, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | - Victoria J Davey
- Office of Research & Development (10X2), Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, District of Columbia
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5
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Forsberg CW, Estrada SA, Baraff A, Magruder KM, Vaccarino V, Litz BT, Friedman MJ, Goldberg J, Smith NL. Risk factors for suicide in the Vietnam-era twin registry. Suicide Life Threat Behav 2022; 52:631-641. [PMID: 35499385 DOI: 10.1111/sltb.12848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND The risk of suicide among Veterans is of major concern, particularly among those who experienced a combat deployment and/or have a history of PTSD. DESIGN AND METHODS This was a retrospective cohort study of post-discharge suicide among Vietnam-era Veterans who are members of the Vietnam Era Twin (VET) Registry. The VET Registry is a national sample of male twins from all branches of the military, both of whom served on active duty between 1964 and 1975. Military service and demographic factors were available from the military records. Service in-theater was based on military records; combat exposure and PTSD symptoms were assessed in 1987 by questionnaire. Mortality follow-up, from discharge to 2016, is identified from Department of Veterans Affairs, Social Security Administration, and National Death Index records; suicide as a cause of death is based on the International Classification of Death diagnostic codes from the death certificate. Statistical analysis used Cox proportional hazards regression to estimate the association of Vietnam-theater service, combat exposure, and PTSD symptoms with suicide while adjusting for military service and demographic confounding factors. RESULTS From the 14,401 twins in the VET Registry, there were 147 suicide deaths during follow-up. In adjusted analyses, twins who served in the Vietnam theater were at similar risk of post-discharge suicide compared with non-theater Veterans; there was no association between combat and suicide. An increase in severity of PTSD symptoms was significantly associated with an increased risk of suicide in adjusted analyses (hazard ratio = 1.13 per five-point increase in symptom score; 95% CI: 1.02-1.27). CONCLUSIONS Service in the Vietnam theater is not associated with greater risk of suicide; however, PTSD symptom severity poses a degree of risk of suicide in Vietnam-era Veterans. Adequate screening for PTSD in Veterans may be promising to identify Veterans who are at increased risk of suicide.
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Affiliation(s)
- Christopher W Forsberg
- Seattle Epidemiologic Research and Information Center Department of Veterans Affairs, Seattle, Washington, USA
| | - Santiago A Estrada
- Seattle Epidemiologic Research and Information Center Department of Veterans Affairs, Seattle, Washington, USA
| | - Aaron Baraff
- Seattle Epidemiologic Research and Information Center Department of Veterans Affairs, Seattle, Washington, USA
| | - Kathryn M Magruder
- Department of Psychiatry, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, US Department of Veteran Affairs, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University, Boston, Massachusetts, USA
| | - Matthew J Friedman
- Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA.,National Center for PTSD, U.S. Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Jack Goldberg
- Seattle Epidemiologic Research and Information Center Department of Veterans Affairs, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Nicholas L Smith
- Seattle Epidemiologic Research and Information Center Department of Veterans Affairs, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
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6
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Cypel Y, Schnurr PP, Schneiderman AI, Culpepper WJ, Akhtar FZ, Morley SW, Fried DA, Ishii EK, Davey VJ. The mental health of Vietnam theater veterans-the lasting effects of the war: 2016-2017 Vietnam Era Health Retrospective Observational Study. J Trauma Stress 2022; 35:605-618. [PMID: 35290689 PMCID: PMC9310606 DOI: 10.1002/jts.22775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 11/11/2022]
Abstract
Mental health data from the 2016-2017 Vietnam Era Health Retrospective Observational Study (VE-HEROeS) were analyzed by cohort, represented by United States Vietnam theater veterans (VTs) who served in Vietnam, Cambodia, and Laos; nontheater veterans (NTs) without theater service; and age- and sex-matched nonveterans (NVs) without military service. The exposure of interest was Vietnam theater service. Surveys mailed to random samples of veterans (n = 42,393) and nonveterans (n = 6,885) resulted in response rates of 45.0% for veterans (n = 6,735 VTs, Mage = 70.09, SE = 0.04; n = 12,131 NTs) and 67.0% for NVs (n = 4,530). We examined self-report data on four mental health outcomes: probable posttraumatic stress disorder (PTSD), depression, psychological distress, and overall mental health functioning. Weighted adjusted odds ratios (aORs) between each outcome and cohort were estimated, controlling for covariates in four models: cohort plus sociodemographic variables (Model 1), Model 1 plus physical health variables (Model 2), Model 2 plus potentially traumatic events (PTEs; Model 3), and Model 3 plus other military service variables (Model 4). Mental health outcome prevalence was highest for VTs versus other cohorts, with the largest aOR, 2.88, for PTSD, 95% CI [2.46, 3.37], p < .001 (Model 4, VT:NT). Physical health and PTEs contributed most to observed effects; other service variables contributed least to aORs overall. Mental health dysfunction persists among VTs years after the war's end. The present results reaffirm previous findings and highlight the need for continued mental health surveillance in VTs.
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Affiliation(s)
- Yasmin Cypel
- Epidemiology Program, Health Outcomes of Military Exposures (12POP5)U.S. Department of Veterans AffairsWashingtonD.C.USA
| | - Paula P. Schnurr
- National Center for PTSDU.S. Department of Veterans AffairsWhite River JunctionVermontUSA,Department of PsychiatryGeisel School of Medicine at DartmouthHanoverNew HampshireUSA
| | - Aaron I. Schneiderman
- Epidemiology Program, Health Outcomes of Military Exposures (12POP5)U.S. Department of Veterans AffairsWashingtonD.C.USA
| | - William J. Culpepper
- Epidemiology Program, Health Outcomes of Military Exposures (12POP5)U.S. Department of Veterans AffairsWashingtonD.C.USA
| | - Fatema Z. Akhtar
- Epidemiology Program, Health Outcomes of Military Exposures (12POP5)U.S. Department of Veterans AffairsWashingtonD.C.USA
| | - Sybil W. Morley
- VISN 2 Center of Excellence for Suicide PreventionU.S. Department of Veterans AffairsCanandaiguaNew YorkUSA
| | - Dennis A. Fried
- War Related Injury & Illness Study CenterU.S. Department of Veterans AffairsEast OrangeNew JerseyUSA
| | - Erick K. Ishii
- Population Health Services (10P4V)U.S. Department of Veterans AffairsWashingtonD.C.USA
| | - Victoria J. Davey
- Office of Research & Development (14RD)U.S. Department of Veterans AffairsWashingtonD.C.USA
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7
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Boice JD, Cohen SS, Mumma MT, Chen H, Golden AP, Beck HL, Till JE. Mortality among U.S. military participants at eight aboveground nuclear weapons test series. Int J Radiat Biol 2020; 98:679-700. [PMID: 32602389 DOI: 10.1080/09553002.2020.1787543] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Approximately 235,000 military personnel participated at one of 230 U.S. atmospheric nuclear weapons tests from 1945 through 1962. At the Nevada Test Site (NTS), the atomic veterans participated in military maneuvers, observed nuclear weapons tests, or provided technical support. At the Pacific Proving Ground (PPG), they served aboard ships or were stationed on islands during or after nuclear weapons tests. MATERIAL AND METHODS Participants at seven test series, previously studied with high-quality dosimetry and personnel records, and the first test at TRINITY formed the cohort of 114,270 male military participants traced for vital status from 1945 through 2010. Dose reconstructions were based on Nuclear Test Personnel Review records, Department of Defense. Standardized mortality ratios (SMR) and Cox and Poisson regression models were used in the analysis. RESULTS Most atomic veterans were enlisted men, served in the Navy at the PPG, and were born before 1930. Vital status was determined for 96.8% of the veterans; 60% had died. Enlisted men had significantly high all-causes mortality SMR (1.06); officers had significantly low all-causes mortality SMR (0.71). The pattern of risk over time showed a diminution of the 'healthy soldier effect': the all-causes mortality SMR after 50 years of follow-up was 1.00. The healthy soldier effect for all cancers also diminished over time. The all-cancer SMR was significantly high after 50 years (SMR 1.10) primarily from smoking-related cancers, attributed in part to the availability of cigarettes in military rations. The highest SMR was for mesothelioma (SMR 1.56) which was correlated with asbestos exposure in naval ships. Prostate cancer was significantly high (SMR 1.13). Ischemic heart disease was significantly low (SMR 0.84). Estimated mean doses varied by organ were low; e.g., the mean red bone marrow dose was 6 mGy (maximum 108 mGy). Internal cohort dose-response analyses provided no evidence for increasing trends with radiation dose for leukemia (excluding chronic lymphocytic leukemia (CLL)) [ERR (95% CI) per 100 mGy -0.37 (-1.08, 0.33); n = 710], CLL, myelodysplastic syndrome, multiple myeloma, ischemic heart disease, or cancers of the lung, prostate, breast, and brain. CONCLUSION No statistically significant radiation associations were observed among 114,270 nuclear weapons test participants followed for up to 65 years. The 95% confidence limits were narrow and excluded mortality risks per unit dose that are two to four times higher than those reported in other investigations. Significantly elevated SMRs were seen for mesothelioma and asbestosis, attributed to asbestos exposure aboard ships.
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Affiliation(s)
- John D Boice
- National Council on Radiation Protection and Measurements, Bethesda, MD, USA.,Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center and Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Sarah S Cohen
- EpidStrategies, a Division of ToxStrategies, Cary, NC, USA
| | | | - Heidi Chen
- Vanderbilt-Ingram Cancer Center, Vanderbilt University, Nashville, TN, USA
| | | | | | - John E Till
- Risk Assessment Corporation, Neeses, SC, USA
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8
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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. Psychosom Med 2020; 82:147-157. [PMID: 31714370 PMCID: PMC8845064 DOI: 10.1097/psy.0000000000000762] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
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.
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9
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Kotzias V, Engel CC, Ramchand R, Ayer L, Predmore Z, Ebener P, Haas GL, Kemp JE, Karras E. Mental Health Service Preferences and Utilization Among Women Veterans in Crisis: Perspectives of Veterans Crisis Line Responders. J Behav Health Serv Res 2019; 46:29-42. [PMID: 30298442 DOI: 10.1007/s11414-018-9635-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Women military veterans are at increased risk of suicide compared to non-veterans, but little is known about the mental health service preferences and needs of women veterans in crisis. This study used qualitative, secondary source key informant interviews to ascertain the experiences of women veterans in crisis from 54 responders working at the Veterans Crisis Line. Responders indicated that women veterans reported different experiences with Veterans Administration (VA) and non-VA care, though drivers of satisfaction or dissatisfaction were similar. Availability of specialty care, sensitivity to veterans' issues or Military Sexual Trauma, strong provider relationships, and continuity of care contributed to satisfaction; lengthy appointment wait times, limited service options, and insensitivity to veterans' issues contributed to dissatisfaction. Responders suggested that barriers limiting VA access for women veterans are perceived as similar to non-VA care. Findings suggest that caller experiences with providers drive satisfaction with VA and non-VA mental health services.
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Affiliation(s)
| | - Charles C Engel
- RAND Corporation, 20 Park Plaza, 9th Floor, Suite 920, Boston, MA, 02116, USA
| | - Rajeev Ramchand
- RAND Corporation, 1200 S. Hayes St., Arlington, VA, 22202, USA
| | - Lynsay Ayer
- RAND Corporation, 1200 S. Hayes St., Arlington, VA, 22202, USA
| | | | - Patricia Ebener
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401-3208, USA
| | - Gretchen L Haas
- VISN 4 MIRECC, Department of Veterans Affairs, 323 North Shore Drive, Suite 400, Pittsburgh, PA, 15212, USA
| | - Janet E Kemp
- VISN 2 Center of Excellence for Suicide Prevention, Department of Veterans Affairs, 400 Fort Hill Ave, Canandaigua, NY, 14424, USA
| | - Elizabeth Karras
- VISN 2 Center of Excellence for Suicide Prevention, Department of Veterans Affairs, 400 Fort Hill Ave, Canandaigua, NY, 14424, USA
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10
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Pless Kaiser A, Kabat DH, Spiro A, Davison EH, Stellman JM. Women at war: The crucible of Vietnam. SSM Popul Health 2018; 3:236-244. [PMID: 29349221 PMCID: PMC5769013 DOI: 10.1016/j.ssmph.2017.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 01/11/2017] [Accepted: 01/12/2017] [Indexed: 11/12/2022] Open
Abstract
Relatively little has been written about the military women who served in Vietnam, and there is virtually no literature on deployed civilian women (non-military). We examined the experiences of 1285 American women, military and civilian, who served in Vietnam during the war and responded to a mail survey conducted approximately 25 years later in which they were asked to report and reflect upon their experiences and social and health histories. We compare civilian women, primarily American Red Cross workers, to military women stratified by length of service, describe their demographic characteristics and warzone experiences (including working conditions, exposure to casualties and sexual harassment), and their homecoming following Vietnam. We assess current health and well-being and also compare the sample to age- and temporally-comparable women in the General Social Survey (GSS), with which our survey shared some measures. Short-term (<10 years) military service women (28%) were more likely to report their Vietnam experience as “highly stressful” than were career (>20 years; 12%) and civilian women (13%). Additional differences regarding warzone experiences, homecoming support, and health outcomes were found among groups. All military and civilian women who served in Vietnam were less likely to have married or have had children than women from the general population, χ2 (8) = 643.72, p < .001. Career military women were happier than women in the general population (48% were “very happy”, as compared to 38%). Civilian women who served in Vietnam reported better health than women in the other groups. Regression analyses indicated that long-term physical health was mainly influenced by demographic characteristics, and that mental health and PTSD symptoms were influenced by warzone and homecoming experiences. Overall, this paper provides insight into the experiences of the understudied women who served in Vietnam, and sheds light on subgroup differences within the sample. Physical health of women deployed to Vietnam was influenced by warzone experiences. Career military women Vietnam veterans are happier than women in general population. Military and non-military Vietnam service women less likely to marry or have kids. Paper provides insight to mostly unstudied lives of American women of Vietnam War.
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Affiliation(s)
- Anica Pless Kaiser
- VA National Center for PTSD, VA Boston Healthcare System and Boston University School of Medicine, 150 S. Huntington Ave, Boston, MA 02130, United States
| | - Daniel H Kabat
- Gold Health Strategies, Inc., 250 Park Ave. Suite 2020, New York, NY 10177, United States
| | - Avron Spiro
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System and Boston University Schools of Public Health and Medicine, 150 S. Huntington Ave (151N), Boston, MA 02130, United States
| | - Eve H Davison
- VA National Center for PTSD, VA Boston Healthcare System and Boston University School of Medicine, 150 S. Huntington Ave, Boston, MA 02130, United States
| | - Jeanne Mager Stellman
- Mailman School of Public Health, Columbia University, New York, NY 10032, United States
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Kilbourne AM, Schumacher K, Frayne SM, Cypel Y, Barbaresso MM, Nord KM, Perzhinsky J, Lai Z, Prenovost K, Spiro A, Gleason TC, Kimerling R, Huang GD, Serpi TB, Magruder KM. Physical Health Conditions Among a Population-Based Cohort of Vietnam-Era Women Veterans: Agreement Between Self-Report and Medical Records. J Womens Health (Larchmt) 2017; 26:1244-1251. [DOI: 10.1089/jwh.2016.6069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Amy M. Kilbourne
- VA Ann Arbor Healthcare System and Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Karen Schumacher
- VA Ann Arbor Healthcare System and Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Susan M. Frayne
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System and Stanford University School of Medicine, Menlo Park, California
| | - Yasmin Cypel
- Post Deployment Health Services (10P4Q), Epidemiology Program, Office of Patient Care Services, Department of Veterans Affairs, Washington, District of Columbia
| | - Michelle M. Barbaresso
- VA Ann Arbor Healthcare System and Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kristina M. Nord
- Office of Research and Development, Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | - Juliette Perzhinsky
- Aleda E. Lutz VAMC and Central Michigan University College of Medicine, Saginaw, Michigan
| | - Zongshan Lai
- Department of Pathology, Beaumont Health System, Troy, Michigan
| | - Katherine Prenovost
- VA Ann Arbor Healthcare System and Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Avron Spiro
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System and Departments of Epidemiology and Psychiatry, Boston University Schools of Public Health and Medicine, Boston, Massachusetts
| | - Theresa C. Gleason
- Patient-Centered Outcomes Research Institute, Clinical Effectiveness & Decision Science, Washington DC
| | - Rachel Kimerling
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System and Stanford University School of Medicine, Menlo Park, California
| | - Grant D. Huang
- Cooperative Studies Program Central Office, VHA Office of Research and Development, Washington, DC
| | - Tracey B. Serpi
- VA Cooperative Studies Program, Veterans Health Administration, Perry Point, Maryland
| | - Kathryn M. Magruder
- Medical University of South Carolina, Charleston, South Carolina, Charleston, South Carolina
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12
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Bergman BP, Mackay DF, Smith DJ, Pell JP. Suicide in Scottish military veterans: a 30-year retrospective cohort study. Occup Med (Lond) 2017; 67:350-355. [DOI: 10.1093/occmed/kqx047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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13
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Weitlauf JC, Washington DL, Stefanick ML. Who Are the Women Veterans in the Women's Health Initiative? THE GERONTOLOGIST 2017; 56 Suppl 1:S6-9. [PMID: 26768392 DOI: 10.1093/geront/gnv674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Julie C Weitlauf
- Veterans Affairs Pal`o Alto Health Care System, Sierra Pacific MIRECC and Center for Implementation to Innovation (Ci2i), Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto.
| | - Donna L Washington
- Veterans Affairs Greater Los Angeles Health Care System, David Geffen School of Medicine, University of California, Los Angeles
| | - Marcia L Stefanick
- Stanford University School of Medicine, Departments of Medicine and Obstetrics and Gynecology, Stanford Prevention Research Center Stanford
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14
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Barth SK, Kang HK, Bullman T. All-Cause Mortality Among US Veterans of the Persian Gulf War: 13-Year Follow-up. Public Health Rep 2016; 131:822-830. [PMID: 28123229 DOI: 10.1177/0033354916676278] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE We determined cause-specific mortality prevalence and risks of Gulf War deployed and nondeployed veterans to determine if deployed veterans were at greater risk than nondeployed veterans for death overall or because of certain diseases or conditions up to 13 years after conflict subsided. METHODS Follow-up began when the veteran left the Gulf War theater or May 1, 1991, and ended on the date of death or December 31, 2004. We studied 621 901 veterans who served in the 1990-1991 Persian Gulf War and 746 247 veterans who served but were not deployed during the Gulf War. We used Cox proportional hazard models to calculate rate ratios adjusted for age at entry to follow-up, length of follow-up, race, sex, branch of service, and military unit. We compared the mortality of (1) Gulf War veterans with non-Gulf War veterans and (2) Gulf War army veterans potentially exposed to nerve agents at Khamisiyah in March 1991 with those not exposed. We compared standardized mortality ratios of deployed and nondeployed Gulf War veterans with the US population. RESULTS Male Gulf War veterans had a lower risk of mortality than male non-Gulf War veterans (adjusted rate ratio [aRR] = 0.97; 95% confidence interval [CI], 0.95-0.99), and female Gulf War veterans had a higher risk of mortality than female non-Gulf War veterans (aRR = 1.15; 95% CI, 1.03-1.28). Khamisiyah-exposed Gulf War army veterans had >3 times the risk of mortality from cirrhosis of the liver than nonexposed army Gulf War veterans (aRR = 3.73; 95% CI, 1.64-8.48). Compared with the US population, female Gulf War veterans had a 60% higher risk of suicide and male Gulf War veterans had a lower risk of suicide (standardized mortality ratio = 0.84; 95% CI, 0.80-0.88). CONCLUSION The vital status and mortality risk of Gulf War and non-Gulf War veterans should continue to be investigated.
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Affiliation(s)
- Shannon K Barth
- Epidemiology Program, Post-Deployment Health Services, Office of Patient Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
| | - Han K Kang
- Epidemiology Program, Post-Deployment Health Services, Office of Patient Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
| | - Tim Bullman
- Epidemiology Program, Post-Deployment Health Services, Office of Patient Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
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Munro IC, Carlo GL, Orr JC, Sund KG, Wilson RM, Kennepohl E, Lynch BS, Jablinske M. A Comprehensive, Integrated Review and Evaluation of the Scientific Evidence Relating to the Safety of the Herbicide 2,4-D. ACTA ACUST UNITED AC 2016. [DOI: 10.3109/10915819209141893] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The safety of 2,4-D to farm and forestry workers, commercial applicators and the general public has been of continuing concern because certain epidemiological studies of groups potentially exposed to 2,4-D have suggested a relationship between 2,4-D use and increased risk of soft tissue sarcoma, Hodgkin's disease or non-Hodgkin's lymphoma. This review on 2,4-D is unique in that the approach taken was to integrate data from worker exposure studies, whole animals, metabolic and other relevant laboratory studies with the epidemiological findings to assess the extent to which there is scientific support for the hypothesis that 2,4-D exposure is associated with any increased risk of human cancer. The case-control epidemiological studies that have been the source of the cancer risk hypothesis are inconclusive. Problems in assessing exposure based on patients' memories make these studies difficult to interpret. Cohort studies of exposed workers do not generally support the specific hypothesis that 2,4-D causes cancer. Taken together, the epidemiological studies provide, at best, only weak evidence of an association between 2,4-D and the risk of cancer. Importantly, the cancer hypothesis is not supported by other data. A critical evaluation of the exposure data indicates that exposure to 2,4-D in user groups is intermittent and much lower than the doses tested chronically in long-term animal studies that have not shown evidence of tumor induction. Moreover, the structure of 2,4-D does not suggest it would be a carcinogen. 2,4-D is a simple organic acid, that is largely excreted unchanged, and there is no evidence that it is metabolized to critically reactive metabolites or accumulates in tissues. This evidence is supported by a large body of negative studies on genotoxicity, which taken together with the metabolic studies, clearly indicates that 2,4-D is highly unlikely to be a genotoxic carcinogen. Furthermore, 2,4-D has no known hormonal activity and does not induce proliferative changes in any tissue or organ, indicating that it does not possess any of the characteristics of non-genotoxic animal carcinogens. Thus the available mechanistic studies provide no plausible basis for a hypothesis of carcinogenicity. In this review, data relating to potential neurotoxicity, immunotoxicity and reproductive toxicity also were evaluated. There is no evidence that 2,4-D adversely affects the immune system and neurotoxic and reproductive effects only have been associated with high toxic doses that would not be encountered by 2,4-D users. Historical exposures to 2,4-D by user groups, particularly farmers, forestry workers and commercial applicators, would be higher than those sustained under present rigorous standards for application which involve the use of protective clothing and other measures to reduce exposure. Proposed label changes indicate that in the future exposures will be even further reduced. Viewed in this context, the available data indicate that the potential public health impact of 2,4-D, including the risk of human cancer, was negligible in the past and would be expected to be even smaller in the present and future.
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Affiliation(s)
- Ian C. Munro
- CanTox Inc., 2233 Argentia Road, Suite 308, Mississauga, Ontario, Canada L5N 2X7
| | - George L. Carlo
- Health & Environmental Sciences Group Ltd., 1513 Sixteenth Street NW, Washington, DC 20036
| | - Joan C. Orr
- CanTox Inc., 2233 Argentia Road, Suite 308, Mississauga, Ontario, Canada L5N 2X7
| | - Kelly G. Sund
- Health & Environmental Sciences Group Ltd., 1513 Sixteenth Street NW, Washington, DC 20036
| | - Ross M. Wilson
- CanTox Inc., 2233 Argentia Road, Suite 308, Mississauga, Ontario, Canada L5N 2X7
| | - Elke Kennepohl
- CanTox Inc., 2233 Argentia Road, Suite 308, Mississauga, Ontario, Canada L5N 2X7
| | - Barry S. Lynch
- CanTox Inc., 2233 Argentia Road, Suite 308, Mississauga, Ontario, Canada L5N 2X7
| | - Maureen Jablinske
- Health & Environmental Sciences Group Ltd., 1513 Sixteenth Street NW, Washington, DC 20036
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16
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Pless Kaiser A, Wang J, Davison EH, Park CL, Mager Stellman J. Stressful and positive experiences of women who served in Vietnam. J Women Aging 2016; 29:26-38. [PMID: 27428167 DOI: 10.1080/08952841.2015.1019812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Anica Pless Kaiser
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Joyce Wang
- MAVERIC, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
- RTI International, Waltham, Massachusetts, USA
| | - Eve H. Davison
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Crystal L. Park
- Department of Psychology, University of Connecticut, Storrs, Connecticut, USA
| | - Jeanne Mager Stellman
- Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York, USA
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17
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Washington DL, Bird CE, LaMonte MJ, Goldstein KM, Rillamas-Sun E, Stefanick ML, Woods NF, Bastian LA, Gass M, Weitlauf JC. Military Generation and Its Relationship to Mortality in Women Veterans in the Women's Health Initiative. THE GERONTOLOGIST 2016; 56 Suppl 1:S126-37. [PMID: 26768386 PMCID: PMC5881617 DOI: 10.1093/geront/gnv669] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 10/05/2015] [Indexed: 11/14/2022] Open
Abstract
PURPOSE OF THE STUDY Women's military roles, exposures, and associated health outcomes have changed over time. However, mortality risk-within military generations or compared with non-Veteran women-has not been assessed. Using data from the Women's Health Initiative (WHI), we examined all-cause and cause-specific mortality by Veteran status and military generation among older women. DESIGN AND METHODS WHI participants (3,719 Veterans; 141,802 non-Veterans), followed for a mean of 15.2 years, were categorized into pre-Vietnam or Vietnam/after generations based on their birth cohort. We used cox proportional hazards models to examine the association between Veteran status and mortality by generation. RESULTS After adjusting for sociodemographic characteristics and WHI study arm, all-cause mortality hazard rate ratios (HRs) for Veterans relative to non-Veterans were 1.16 (95% CI: 1.09-1.23) for pre-Vietnam and 1.16 (95% CI: 0.99-1.36) for Vietnam/after generations. With additional adjustment for health behaviors and risk factors, this excess mortality rate persisted for pre-Vietnam but attenuated for Vietnam/after generations. After further adjustment for medical morbidities, across both generations, Veterans and non-Veterans had similar all-cause mortality rates. Relative to non-Veterans, adjusting for sociodemographics and WHI study arm, pre-Vietnam generation Veterans had higher cancer, cardiovascular, and trauma-related morality rates; Vietnam/after generation Veterans had the highest trauma-related mortality rates (HR = 2.93, 1.64-5.23). IMPLICATIONS Veterans' higher all-cause mortality rates were limited to the pre-Vietnam generation, consistent with diminution of the healthy soldier effect over the life course. Mechanisms underlying Vietnam/after generation Veteran trauma-related mortality should be elucidated. Efforts to modify salient health risk behaviors specific to each military generation are needed.
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Affiliation(s)
- Donna L Washington
- VA Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, California. University of California Los Angeles, Geffen School of Medicine.
| | - Chloe E Bird
- RAND Corporation, Pardee Rand Graduate School, Santa Monica, California
| | - Michael J LaMonte
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, State University of New York at Buffalo
| | | | | | - Marcia L Stefanick
- Stanford University School of Medicine, Stanford Center for Health Research on Women & Sex Differences in Medicine, California
| | - Nancy F Woods
- Division of Biobehavioral Nursing & Health Systems, University of Washington School of Nursing, Seattle
| | - Lori A Bastian
- VA Connecticut, and University of Connecticut Health Center, West Haven
| | - Margery Gass
- The North American Menopause Society, Mayfield Heights, Ohio
| | - Julie C Weitlauf
- VA Palo Alto Health Care System, Sierra Pacific MIRECC and Center for Innovation to Implementation, California. Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, California
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18
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Schlenger WE, Corry NH, Williams CS, Kulka RA, Mulvaney-Day N, DeBakey S, Murphy CM, Marmar CR. A Prospective Study of Mortality and Trauma-Related Risk Factors Among a Nationally Representative Sample of Vietnam Veterans. Am J Epidemiol 2015; 182:980-90. [PMID: 26634285 DOI: 10.1093/aje/kwv217] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 08/12/2015] [Indexed: 11/13/2022] Open
Abstract
Because Vietnam veterans comprise the majority of all living veterans and most are now older adults, the urgency and potential value of studying the long-term health effects of service in the Vietnam War, including effects on mortality, is increasing. The present study is the first prospective mortality assessment of a representative sample of Vietnam veterans. We used one of the longest follow-up periods to date (spanning older adulthood) and conducted one of the most comprehensive assessments of potential risk factors. Vital status and cause of death were ascertained for the 1,632 veterans who fought in the Vietnam theater (hereafter referred to as theater veterans) and for 716 Vietnam War-era veterans (hereafter referred to as era veterans) who participated in the National Vietnam Veterans Readjustment Study (1987-2011). As of April 2011, 16.0% (95% confidence interval: 13.1, 19.0) of all Vietnam veterans who were alive in the 1980s were deceased. Male theater veterans with a high probability of posttraumatic stress disorder (PTSD) were nearly 2 times more likely to have died than were those without PTSD, even after adjustment for sociodemographic and other characteristics. A high level of exposure to war zone stress was independently associated with mortality for both male and female theater veterans after adjustment for sociodemographic characteristics, PTSD, and physical comorbid conditions. Theater veterans with a high level of exposure to war zone stress and a high probability of PTSD had the greatest mortality risk (adjusted hazard ratio = 2.34, 95% confidence interval: 1.24, 4.43).
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19
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Weitlauf JC, LaCroix AZ, Bird CE, Woods NF, Washington DL, Katon JG, LaMonte MJ, Goldstein MK, Bassuk SS, Sarto G, Stefanick ML. Prospective Analysis of Health and Mortality Risk in Veteran and Non-Veteran Participants in the Women's Health Initiative. Womens Health Issues 2015; 25:649-57. [PMID: 26432346 PMCID: PMC4641800 DOI: 10.1016/j.whi.2015.08.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 08/17/2015] [Accepted: 08/17/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND The health of postmenopausal women veterans is a neglected area of study. A stronger empirical evidence base is needed, and would inform the provision of health care for the nearly 1 million U.S. women veterans currently 50 years of age or older. To this end, the present work compares salient health outcomes and risk of all-cause mortality among veteran and non-veteran participants of the Women's Health Initiative (WHI). METHODS This study features prospective analysis of long-term health outcomes and mortality risk (average follow-up, 8 years) among the 3,706 women veterans and 141,009 non-veterans who participated in the WHI Observational Study or Clinical Trials. Outcome measurements included confirmed incident cases of cardiovascular disease (CVD), cancer, diabetes, hip fractures, and all-cause mortality. RESULTS We identified 17,968 cases of CVD, 19,152 cases of cancer, 18,718 cases of diabetes, 2,817 cases of hip fracture, and 13,747 deaths. In Cox regression models adjusted for age, sociodemographic variables, and health risk factors, veteran status was associated with significantly increased risk of all-cause mortality (hazard ratio [HR], 1.13; 95% CI, 1.03-1.23), but not with risk of CVD (HR, 1.00; 95% CI, 0.90-1.11), cancer (HR, 1.04; 95% CI, 0.95-1.14), hip fracture (HR, 1.16; 95% CI, 0.94-1.43), or diabetes (HR, 1.00; 95% CI, 0.89-1.1). CONCLUSIONS Women veterans' postmenopausal health, particularly risk for all-cause mortality, warrants further consideration. In particular, efforts to identify and address modifiable risk factors associated with all-cause mortality are needed.
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Affiliation(s)
- Julie C. Weitlauf
- Veterans Affairs Palo Alto Health Care System, Mental Illness Research, Educationa and Clinical Center (151Y), 3801 Miranda Ave, Palo Alto, California (USA) 94304
- Stanford School of Medicine, Department of Psychiatry and Behavioral Sciences, 401 Quarry Road, Stanford, California (USA) 94305-5717
| | - Andrea Z. LaCroix
- University of California, San Diego, Division of Epidemiology, Family and Preventive Medicine, 9500 Gilman Drive #0725, La Jolla, California (USA) 92093-0725
| | - Chloe E. Bird
- RAND Corporation
- RAND Pardee Graduate school, 1776 Main Street, PO Box 2138, Santa Monica, California (USA) 90407-2138
| | - Nancy F. Woods
- University of Washington, School of Nursing, Box 357266, Seattle, Washington (USA) 98195
| | - Donna L. Washington
- VA Greater Los Angeles Health Care System, Center for the Study of Healthcare Innovation, Implementation and Policy, 11301 Wilshire Blvd., 111G, Los Angeles, California (USA) 90073
- University of California, Los Angeles, David Geffen School of Medicine, Department of Medicine, 10833 Le Conte Avenue, Los Angeles, California (USA) 90095
| | - Jodie G. Katon
- VA Puget Sound Health Care System, (Met Park) 1100 Olive Way suite 1400, Seattle, Washington (USA) 98101
- University of Washington, School of Public Health, Box 357230, Seattle, Washington (USA) 98195
| | - Michael J. LaMonte
- State University of New York at Buffalo, Department of Epidemiology & Environmental Health, School of Public Health and Health Professions, 273 Farber Hall; 3435 Main Street, Buffalo, New York (USA) 14214-8001
| | - Mary K. Goldstein
- Veterans Affairs Palo Alto Health Care System, Geriatrics Research, Education and Clinical Center, 3801 Miranda Ave, Palo Alto, CA (USA) 94304
- Stanford University School of Medicine, Department of Medicine, Center for Primary Care & Outcomes Research, 117 Encina Commons Stanford University, Stanford, California (USA) 94305-6006
| | - Shari S. Bassuk
- Division of Preventive Medicine, Brigham and Women’s Hospital, 900 Commonwealth Avenue East, Boston, Massachusetts 02215
| | - Gloria Sarto
- University of Wisconsin-Madison, School of Medicine & Public Health, Department of Obstetrics and Gynecology, 750 Highland Avenue, Madison, Wisconsin (USA) 53726
| | - Marcia L. Stefanick
- Stanford University School of Medicine, Department of Medicine: Stanford Center for Prevention Research, Medical School Office Building, 1265 Welch Rd, Room X308, Stanford, California (USA) 94305-5411
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20
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Magruder K, Serpi T, Kimerling R, Kilbourne AM, Collins JF, Cypel Y, Frayne SM, Furey J, Huang GD, Gleason T, Reinhard MJ, Spiro A, Kang H. Prevalence of Posttraumatic Stress Disorder in Vietnam-Era Women Veterans: The Health of Vietnam-Era Women's Study (HealthVIEWS). JAMA Psychiatry 2015; 72:1127-34. [PMID: 26445103 PMCID: PMC7529477 DOI: 10.1001/jamapsychiatry.2015.1786] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Many Vietnam-era women veterans served in or near war zones and may have experienced stressful or traumatic events during their service. Although posttraumatic stress disorder (PTSD) is well studied among men who served in Vietnam, no major epidemiologic investigation of PTSD among women has been performed. OBJECTIVES To assess (1) the onset and prevalence of lifetime and current PTSD for women who served during the Vietnam era, stratified by wartime location (Vietnam, near Vietnam, or the United States), and (2) the extent to which wartime location was associated with PTSD, with adjustment for demographics, service characteristics, and wartime exposures. DESIGN, SETTING, AND PARTICIPANTS Survey of 8742 women who were active-duty military personnel in the US Armed Forces at any time from July 4, 1965, through March 28, 1973, and alive as of survey receipt as part of Department of Veterans Affairs Cooperative Study 579, HealthVIEWS. Data were obtained from mailed and telephone surveys from May 16, 2011, through August 5, 2012, and analyzed from June 26, 2013, through July 30, 2015. MAIN OUTCOMES AND MEASURES Lifetime and current PTSD as measured by the PTSD module of the Composite International Diagnostic Interview, version 3.0; onset of PTSD; and wartime experiences as measured by the Women's Wartime Exposure Scale-Revised. RESULTS Among the 4219 women (48.3%) who completed the survey and a telephone interview, the weighted prevalence (95% CI) of lifetime PTSD was 20.1% (18.3%-21.8%), 11.5% (9.1%-13.9%), and 14.1% (12.4%-15.8%) for the Vietnam, near-Vietnam, and US cohorts, respectively. The weighted prevalence (95% CI) of current PTSD was 15.9% (14.3%-17.5%), 8.1% (6.0%-10.2%), and 9.1% (7.7%-10.5%) for the 3 cohorts, respectively. Few cases of PTSD among the Vietnam or near-Vietnam cohorts were attributable to premilitary onset (weighted prevalence, 2.9% [95% CI, 2.2%-3.7%] and 2.9% [95% CI, 1.7%-4.2%], respectively). Unadjusted models for lifetime and current PTSD indicated that women who served in Vietnam were more likely to meet PTSD criteria than women who mainly served in the United States (odds ratio [OR] for lifetime PTSD, 1.53 [95% CI, 1.28-1.83]; OR for current PTSD, 1.89 [95% CI, 1.53-2.33]). When we adjusted for wartime exposures, serving in Vietnam or near Vietnam did not increase the odds of having current PTSD (adjusted ORs, 1.05 [95% CI, 0.75-1.46] and 0.77 [95% CI, 0.52-1.14], respectively). CONCLUSIONS AND RELEVANCE The prevalence of PTSD for the Vietnam cohort was higher than previously documented. Vietnam service significantly increased the odds of PTSD relative to US service; this effect appears to be associated with wartime exposures, especially sexual discrimination or harassment and job performance pressures. Results suggest long-lasting mental health effects of Vietnam-era service among women veterans.
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Affiliation(s)
- Kathryn Magruder
- Mental Health Service, Ralph H. Johnson Veterans Affairs (VA) Medical Center, Charleston, South Carolina2Department of Psychiatry, Medical University of South Carolina, Charleston
| | - Tracey Serpi
- Cooperative Studies Program Coordinating Center, VA Maryland Health Care System, Perry Point
| | - Rachel Kimerling
- National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California5Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
| | - Amy M. Kilbourne
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan7Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Joseph F. Collins
- Cooperative Studies Program Coordinating Center, VA Maryland Health Care System, Perry Point
| | - Yasmin Cypel
- US Department of Veterans Affairs, Office of Public Health, Post Deployment Strategic Healthcare Group, Washington, DC
| | - Susan M. Frayne
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California9Division of General Medical Disciplines, Stanford University School of Medicine, Palo Alto, California
| | | | - Grant D. Huang
- Cooperative Studies Program Central Office, VA Office of Research and Development, Washington, DC
| | - Theresa Gleason
- Clinical Science Research and Development, VA Office of Research and Development, Washington, DC
| | - Matthew J. Reinhard
- War Related Illness and Injury Center, Washington, DC14Department of Psychiatry, Georgetown University Medical School, Washington, DC
| | - Avron Spiro
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts16Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts17Department of Psychiatry, Boston Univers
| | - Han Kang
- US Department of Veterans Affairs, Office of Public Health, Post Deployment Strategic Healthcare Group, Washington, DC
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Chang ET, Boffetta P, Adami HO, Mandel JS. A critical review of the epidemiology of Agent Orange or 2,3,7,8-tetrachlorodibenzo-p-dioxin and lymphoid malignancies. Ann Epidemiol 2015; 25:275-292.e30. [DOI: 10.1016/j.annepidem.2015.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 01/06/2015] [Accepted: 01/09/2015] [Indexed: 12/20/2022]
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Kimerling R, Serpi T, Weathers F, Kilbourne AM, Kang H, Collins JF, Cypel Y, Frayne SM, Furey J, Huang GD, Reinhard MJ, Spiro A, Magruder K. Diagnostic accuracy of the Composite International Diagnostic Interview (CIDI 3.0) PTSD module among female Vietnam-era veterans. J Trauma Stress 2014; 27:160-7. [PMID: 24740869 DOI: 10.1002/jts.21905] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) posttraumatic stress disorder (PTSD) module is widely used in epidemiological studies of PTSD, yet relatively few data attest to the instrument's diagnostic utility. The current study evaluated the diagnostic utility of the CIDI 3.0 PTSD module with U. S. women Vietnam-era veterans. The CIDI and the Clinician-Administered PTSD Scale (CAPS) were independently administered to a stratified sample of 160 women, oversampled for current PTSD. Both lifetime PTSD and recent (past year) PTSD were assessed within a 3-week interval. Forty-five percent of the sample met criteria for a CAPS diagnosis of lifetime PTSD, and 21.9% of the sample met criteria for a CAPS diagnosis of past-year PTSD. Using CAPS as the diagnostic criterion, the CIDI correctly classified 78.8% of cases for lifetime PTSD (κ = .56) and 82.0% of past year PTSD cases (κ = .51). Estimates of diagnostic performance for the CIDI were sensitivity of .61 and specificity of .91 for lifetime PTSD and sensitivity of .71 and specificity of .85 for past-year PTSD. Results suggest that the CIDI has good utility for identifying PTSD, though it is a somewhat conservative indicator of lifetime PTSD as compared to the CAPS.
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Affiliation(s)
- Rachel Kimerling
- National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, USA; Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA
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Kang HK, Cypel Y, Kilbourne AM, Magruder KM, Serpi T, Collins JF, Frayne SM, Furey J, Huang GD, Kimerling R, Reinhard MJ, Schumacher K, Spiro A. HealthViEWS: mortality study of female US Vietnam era veterans, 1965-2010. Am J Epidemiol 2014; 179:721-30. [PMID: 24488510 DOI: 10.1093/aje/kwt319] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We conducted a retrospective study among 4,734 women who served in the US military in Vietnam (Vietnam cohort), 2,062 women who served in countries near Vietnam (near-Vietnam cohort), and 5,313 nondeployed US military women (US cohort) to evaluate the associations of mortality outcomes with Vietnam War service. Veterans were identified from military records and followed for 40 years through December 31, 2010. Information on underlying causes of death was obtained from death certificates and the National Death Index. Based on 2,743 deaths, all 3 veteran cohorts had lower mortality risk from all causes combined and from several major causes, such as diabetes mellitus, heart disease, chronic obstructive pulmonary disease, and nervous system disease relative to comparable US women. However, excess deaths from motor vehicle accidents were observed in the Vietnam cohort (standardized mortality ratio = 3.67, 95% confidence interval (CI): 2.30, 5.56) and in the US cohort (standardized mortality ratio = 1.91, 95% CI: 1.02, 3.27). More than two-thirds of women in the study were military nurses. Nurses in the Vietnam cohort had a 2-fold higher risk of pancreatic cancer death (adjusted relative risk = 2.07, 95% CI: 1.00, 4.25) and an almost 5-fold higher risk of brain cancer death compared with nurses in the US cohort (adjusted relative risk = 4.61, 95% CI: 1.27, 16.83). Findings of all-cause and motor vehicle accident deaths among female Vietnam veterans were consistent with patterns of postwar mortality risk among other war veterans.
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Zohar J, Fostick L. Mortality rates between treated post-traumatic stress disorder Israeli male veterans compared to non-diagnosed veterans. Eur Neuropsychopharmacol 2014; 24:117-24. [PMID: 24239328 DOI: 10.1016/j.euroneuro.2013.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 10/15/2013] [Accepted: 10/19/2013] [Indexed: 11/25/2022]
Abstract
The literature suggests that post-traumatic stress disorder (PTSD) is associated with increased mortality. However, to date, mortality rates amongst veterans diagnosed with post-traumatic stress disorder have not been reported for Israeli veterans, who bear a different profile than veterans from other countries. This study aims to evaluate age-adjusted mortality rates amongst Israeli Defense Forces veterans with and without PTSD diagnosis. The study was carried out in a paired sample design with 2457 male veterans with treated PTSD and 2457 matched male veterans without a PTSD diagnosis. Data on PTSD and non-PTSD veterans was collected from the Rehabilitation Division of the Israeli Ministry of Defense (MOD) and the Israeli Defense Forces' (IDF) special unit for treatment of combat stress reaction. Mortality data were collected from the Ministry of the Interior (MOI) computerized database. Comparison of mortality rates between PTSD and non-PTSD veterans was done using paired observations survival analysis by applying a proportional hazards regression model. Overall no statistically significant difference in mortality rates was found between veterans with treated PTSD and veterans without PTSD. These findings hold even when excluding veterans who died in battle and including non-PTSD veterans who died before their matched PTSD veteran was diagnosed. However, among pairs with similar military jobs PTSD group had significantly less mortality. The results of this large national cohort suggest that treated PTSD is not associated with increased mortality. We submit that the lack of this association represents the "net" pathophysiology of PTSD due to the unique characteristics of the sample.
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Affiliation(s)
- Joseph Zohar
- Department of Psychiatry, Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Israel.
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Wiltsey Stirman S, Shields N, Deloriea J, Landy MSH, Belus JM, Maslej MM, Monson CM. A randomized controlled dismantling trial of post-workshop consultation strategies to increase effectiveness and fidelity to an evidence-based psychotherapy for Posttraumatic Stress Disorder. Implement Sci 2013; 8:82. [PMID: 23902798 PMCID: PMC3750558 DOI: 10.1186/1748-5908-8-82] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 07/26/2013] [Indexed: 11/10/2022] Open
Abstract
Background Posttraumatic Stress Disorder (PTSD) is a serious mental health condition with substantial costs to individuals and society. Among military veterans, the lifetime prevalence of PTSD has been estimated to be as high as 20%. Numerous research studies have demonstrated that short-term cognitive-behavioral psychotherapies, such as Cognitive Processing Therapy (CPT), lead to substantial and sustained improvements in PTSD symptoms. Despite known benefits, only a minority of clinicians provide these therapies. Transferring this research knowledge into clinical settings remains one of the largest hurdles to improving the health of veterans with PTSD. Attending a workshop alone is insufficient to promote adequate knowledge transfer and sustained skill; however, relatively little research has been conducted to identify effective post-training support strategies. Methods The current study investigates whether clinicians receiving post-workshop support (six-month duration) will deliver CPT with greater fidelity (i.e., psychotherapy adherence and competence) and have improved patient outcomes compared with clinicians receiving no formal post-workshop support. The study conditions are: technology-enhanced group tele-consultation; standard group tele-consultation; and fidelity assessment with no consultation. The primary outcome is independent assessment (via audio-recordings) of the clinicians’ adherence and competence in delivering CPT. The secondary outcome is observed changes in patient symptoms during and following treatment as a function of clinician fidelity. Post-consultation interviews with clinicians will help identify facilitators and barriers to psychotherapy skill acquisition. The study results will inform how best to implement and transfer evidence-based psychotherapy (e.g., CPT) to clinical settings to attain comparable outcomes to those observed in research settings. Discussion Findings will deepen our understanding of how much and what type of support is needed following a workshop to help clinicians become proficient in delivering a new protocol. Several influences on clinician learning and patient outcomes will be discussed. An evidence-based model of clinical consultation will be developed, with the ultimate goal of informing policy and influencing best practice in clinical consultation. Trial registration ClinicalTrials.gov: NCT01861769
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Affiliation(s)
- Shannon Wiltsey Stirman
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston University, 150 South Huntington Ave (116B3), Boston, MA 02130, USA
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Washington DL, Bean-Mayberry B, Hamilton AB, Cordasco KM, Yano EM. Women veterans' healthcare delivery preferences and use by military service era: findings from the National Survey of Women Veterans. J Gen Intern Med 2013; 28 Suppl 2:S571-6. [PMID: 23807067 PMCID: PMC3695266 DOI: 10.1007/s11606-012-2323-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The number of women Veterans (WVs) utilizing the Veterans Health Administration (VA) has doubled over the past decade, heightening the importance of understanding their healthcare delivery preferences and utilization patterns. Other studies have identified healthcare issues and behaviors of WVs in specific military service eras (e.g., Vietnam), but delivery preferences and utilization have not been examined within and across eras on a population basis. OBJECTIVE To identify healthcare delivery preferences and healthcare use of WVs by military service era to inform program design and patient-centeredness. DESIGN AND PARTICIPANTS Cross-sectional 2008-2009 survey of a nationally representative sample of 3,611 WVs, weighted to the population. MAIN MEASURES Healthcare delivery preferences measured as importance of selected healthcare features; types of healthcare services and number of visits used; use of VA or non-VA; all by military service era. KEY RESULTS Military service era differences were present in types of healthcare used, with World War II and Korea era WVs using more specialty care, and Vietnam era-to-present WVs using more women's health and mental health care. Operations Enduring Freedom, Iraqi Freedom, New Dawn (OEF/OIF/OND) WVs made more healthcare visits than WVs of earlier military eras. The greatest healthcare delivery concerns were location convenience for Vietnam and earlier WVs, and cost for Gulf War 1 and OEF/OIF/OND WVs. Co-located gynecology with general healthcare was also rated important by a sizable proportion of WVs from all military service eras. CONCLUSIONS Our findings point to the importance of ensuring access to specialty services closer to home for WVs, which may require technology-supported care. Younger WVs' higher mental health care use reinforces the need for integration and coordination of primary care, reproductive health and mental health care.
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Affiliation(s)
- Donna L Washington
- VA Greater Los Angeles Health Services Research and Development (HSR&D) Center of Excellence for the Study of Healthcare Provider Behavior, Sepulveda, CA USA.
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Abstract
Military veterans represent a unique, heterogeneous population with suicide prevalence rates, risk factors and preventative management needs that differ from those of the rest of community. Veterans worldwide receive high proportions of their healthcare from community providers, and sensitivity to these distinct needs is required for optimized care. An overview of the recent prevalence-study literature, with a focus upon statistical design, is presented in order to provide a critical orientation within this field with high levels of popular media attention. Attention to psychiatric comorbidity, subthreshold symptomology, select signature disorders of contemporary conflicts (namely, post-traumatic stress disorder and traumatic brain injury), and veteran life narratives before, within and beyond military service will guide our review of risk factor assessment and management strategies. This critical review of the literature provides an overview of this active field of neuropsychiatric research with a select focus upon these topics of special interest.
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Affiliation(s)
- Timothy R Rice
- Department of Psychiatry, The Mount Sinai School of Medicine, 1425 Madison Avenue, Box 1230, New York, NY 10029, USA.
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Blow FC, Bohnert ASB, Ilgen MA, Ignacio R, McCarthy JF, Valenstein MM, Knox KL. Suicide mortality among patients treated by the Veterans Health Administration from 2000 to 2007. Am J Public Health 2012; 102 Suppl 1:S98-104. [PMID: 22390612 DOI: 10.2105/ajph.2011.300441] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We sought to examine rates of suicide among individuals receiving health care services in Veterans Health Administration (VHA) facilities over an 8-year period. METHODS We included annual cohorts of all individuals who received VHA health care services from fiscal year (FY) 2000 through FY 2007 (October 1, 1999-September 30, 2007; N = 8,855,655). Vital status and cause of death were obtained from the National Death Index. RESULTS Suicide was more common among VHA patients than members of the general US population. The overall rates of suicide among VHA patients decreased slightly but significantly from 2000 to 2007 (P < .001). Male veterans between the ages of 30 and 64 years were at the highest risk of suicide. CONCLUSIONS VHA health care system patients are at elevated risk for suicide and are appropriate for suicide reduction services, although the rate of suicide has decreased in recent years for this group. Comprehensive approaches to suicide prevention in the VHA focus not only on recent returnees from Iraq and Afghanistan but also on middle-aged and older Veterans.
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Affiliation(s)
- Frederic C Blow
- Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC) and Health Services Research and Development Center of Excellence, Ann Arbor, MI, USA.
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Kunnas T, Solakivi T, Renko J, Kalela A, Nikkari ST. Late-life coronary heart disease mortality of Finnish war veterans in the TAMRISK study, a 28-year follow-up. BMC Public Health 2011; 11:71. [PMID: 21284848 PMCID: PMC3038159 DOI: 10.1186/1471-2458-11-71] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Accepted: 02/01/2011] [Indexed: 11/10/2022] Open
Abstract
Background Wartime stress has been associated with increased late-life mortality of all causes of death. We evaluated whether wounded Finnish World War II veterans who were alive at the age of 55 have increased long-term coronary heart disease (CHD) mortality. Methods Health survey data were recorded in 1980 from 667 men, aged 55 years. Of them 102 had been wounded or injured in action during 1939-1945. The remaining participants served as the comparison group. The death certificates during a 28-year follow-up were obtained from the national statistics centre. Statistical comparisons were done by Cox proportional hazard regression model. Results There were altogether 140 deaths from CHD. In men who had been wounded or injured in action the crude CHD mortality rate per 10,000 population was 2843, while in the comparison group the corresponding figure was 1961. Men who had been wounded or injured in action were 1.7 times (95% CI 1.1-2.5; p = 0.01) more likely to die from CHD than the comparison group. Conclusions Physical trauma at young adulthood may extend to lifelong effects on health. This study suggests that being physically wounded or injured in war may lead to increased CHD mortality in late adulthood in a Finnish population.
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Affiliation(s)
- Tarja Kunnas
- Department of Medical Biochemistry, University of Tampere Medical School, Tampere, Finland
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Roelfs D, Shor E, Davidson K, Schwartz J. War-related stress exposure and mortality: a meta-analysis. Int J Epidemiol 2010; 39:1499-509. [PMID: 20724455 DOI: 10.1093/ije/dyq132] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Domestic and international wars continue to be pervasive in the 21st century. This study summarizes the effects of war-related stress on all-cause mortality using meta-analyses and meta-regressions. METHODS A keyword search was performed, supplemented by extensive iterative hand-searches for observational studies of war-related stress and mortality. Two hundred and twenty mortality risk estimates from 30 studies were extracted, providing data on more than 9 million persons. RESULTS The mean hazard ratio (HR) was 1.05 [95% confidence interval (CI) 0.98-1.13] among HRs adjusted for age and additional covariates. The mean effect for men was 1.14 (CI 1.00-1.31), and for women it was 0.92 (CI 0.66-1.28). No differences were found for various follow-up durations or for various types of war stress. Neither civilians nor military personnel had an elevated mortality risk. Those exposed to a combat zone during the Vietnam War had a slightly higher chance of death (HR 1.11; 95% CI 1.00-1.23). CONCLUSIONS The results show that, over all, exposure to war-stress did not increase the risk of death when studies were well controlled. Effects were small when found. This lack of substantial effect may be the result of selection processes, developed resiliency and/or institutional support.
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Affiliation(s)
- David Roelfs
- Department of Sociology, Stony Brook University, Stony Brook, NY, USA
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Military combat and risk of coronary heart disease and ischemic stroke in aging men: The Atherosclerosis Risk in Communities (ARIC) study. Ann Epidemiol 2010; 20:143-50. [PMID: 20123165 DOI: 10.1016/j.annepidem.2009.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Revised: 09/08/2009] [Accepted: 10/12/2009] [Indexed: 11/21/2022]
Abstract
PURPOSE To assess the long-term association of military combat stress with coronary heart disease (CHD) and ischemic stroke (IS). METHODS The association between exposure to military combat and the occurrence of CHD and IS was assessed among 5,347 men in the Atherosclerosis Risk in Communities (ARIC) study. Outcomes were assessed an average of 36 years after entry into military service during the eras of World War II, the Korean War, and the Vietnam conflict. RESULTS Veterans were more likely to be older, white, and of higher socioeconomic status than non-veterans. No differences in CHD period prevalence rates were noted among the three exposure groups, overall or by era of service. Associations between combat and ischemic stroke period prevalence may be modified by father's education, although confidence intervals were wide and event rates small. CONCLUSIONS Overall, middle-aged veterans with distant combat exposure are not at increased cardiovascular risk compared to those without combat exposure.
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Knapik JJ, Marin RE, Grier TL, Jones BH. A systematic review of post-deployment injury-related mortality among military personnel deployed to conflict zones. BMC Public Health 2009; 9:231. [PMID: 19594931 PMCID: PMC2720964 DOI: 10.1186/1471-2458-9-231] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 07/13/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This paper reports on a systematic review of the literature on the post-conflict injury-related mortality of service members who deployed to conflict zones. METHODS Literature databases, reference lists of articles, agencies, investigators, and other sources were examined to find studies comparing injury-related mortality of military veterans who had served in conflict zones with that of contemporary veterans who had not served in conflict zones. Injury-related mortality was defined as a cause of death indicated by International Classification of Diseases E-codes E800 to E999 (external causes) or subgroupings within this range of codes. RESULTS Twenty studies met the review criteria; all involved veterans serving during either the Vietnam or Persian Gulf conflict. Meta-analysis indicated that, compared with non-conflict-zone veterans, injury-related mortality was elevated for veterans serving in Vietnam (summary mortality rate ratio (SMRR) = 1.26, 95% confidence interval (95%CI) = 1.08-1.46) during 9 to 18 years of follow-up. Similarly, injury-related mortality was elevated for veterans serving in the Persian Gulf War (SMRR = 1.26, 95%CI = 1.16-1.37) during 3 to 8 years of follow-up. Much of the excess mortality among conflict-zone veterans was associated with motor vehicle events. The excess mortality decreased over time. Hypotheses to account for the excess mortality in conflict-zone veterans included post-traumatic stress, coping behaviors such as substance abuse, ill-defined diseases and symptoms, lower survivability in injury events due to conflict-zone comorbidities, altered perceptions of risk, and/or selection processes leading to the deployment of individuals who were risk-takers. CONCLUSION Further research on the etiology of the excess mortality in conflict-zone veterans is warranted to develop appropriate interventions.
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Affiliation(s)
- Joseph J Knapik
- US Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, MD, USA
| | - Roberto E Marin
- Occupational Medicine Department, Womack Army Medical Center, Fort Bragg, NC, USA
| | - Tyson L Grier
- US Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, MD, USA
| | - Bruce H Jones
- US Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, MD, USA
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McCarthy JF, Valenstein M, Kim HM, Ilgen M, Zivin K, Blow FC. Suicide mortality among patients receiving care in the veterans health administration health system. Am J Epidemiol 2009; 169:1033-8. [PMID: 19251753 DOI: 10.1093/aje/kwp010] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Understanding and reducing mortality from suicide among veterans is a national priority, particularly for individuals receiving care from the US Veterans Health Administration (VHA). This report examines suicide rates among VHA patients and compares them with rates in the general population. Suicide mortality was assessed in fiscal year 2001 for patients alive at the start of that fiscal year and with VHA use in fiscal years 2000-2001 (n = 4,692,034). Deaths from suicide were identified by using National Death Index data. General population rates were identified by use of the Web-based Injury Statistics Query and Reporting System. VHA rates were 43.13/100,000 person-years for men and 10.41/100,000 person-years for women. For male patients, the age-adjusted standardized mortality ratio was 1.66; for females, it was 1.87. Male patients aged 30-79 years had increased risks relative to men in the general population; standardized mortality ratios ranged from 2.56 (ages 30-39 years) to 1.33 (ages 70-79 years). Female patients aged 40-59 years had greater risks than did women in the general population, with standardized mortality ratios of 2.15 (ages 40-49 years) and 2.36 (ages 50-59 years). Findings offer heretofore unavailable comparison points for health systems. Prior to the conflicts in Afghanistan and Iraq and before recent VHA initiatives, rates were higher among VHA patients than in the general population. Female patients had particularly high relative risks.
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Affiliation(s)
- John F McCarthy
- US Department of Veterans Affairs Serious Mental Illness Treatment Research and Evaluation Center, Ann Arbor, Michigan 48113-0170, USA.
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McLaughlin R, Nielsen L, Waller M. An Evaluation of the Effect of Military Service on Mortality: Quantifying the Healthy Soldier Effect. Ann Epidemiol 2008; 18:928-36. [DOI: 10.1016/j.annepidem.2008.09.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2008] [Revised: 08/26/2008] [Accepted: 09/04/2008] [Indexed: 10/21/2022]
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Mortality patterns among women Vietnam-era veterans: results of a retrospective cohort study. Ann Epidemiol 2008; 18:244-52. [PMID: 18280922 DOI: 10.1016/j.annepidem.2007.11.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2007] [Revised: 10/19/2007] [Accepted: 11/15/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE This research compiled and analyzed the data of two cohorts of women veterans who either served in Vietnam ("Vietnam veteran" cohort, n = 4586) or served elsewhere during the Vietnam War ("non-Vietnam veteran" cohort, n = 5325). All cause and cause-specific mortality were compared between Vietnam and non-Vietnam veteran cohorts, to the U.S. population, and to earlier research. Similar analyses were performed for nurses only. METHODS Vital status was determined through December 31, 2004, using primarily the U.S. Department of Veterans Affairs beneficiary file and the Social Security Administration Death Master File. Selected data were submitted to the National Center for Health Statistics for merging with the National Death Index to obtain cause of death. Cox proportional hazard analysis modeling was used to obtain adjusted relative risks (ARR). SEER( *)Stat software was used to compute standardized mortality ratios (SMR) for comparisons to the U.S. population. RESULTS Women Vietnam veterans showed a significant deficit (ARR = 0.78, 95% confidence interval [CI] 0.62-0.98) in circulatory system disease relative to non-Vietnam veterans, but significant deficits also were observed when the Vietnam and non-Vietnam cohorts were each compared with women in the U.S. population (SMR = 0.65, 95% CI 0.54-0.77; SMR=0.82, 95% CI 0.73-0.93, respectively). Vietnam veterans had significantly lower mortality than women in the U.S. population for all causes (SMR = 0.87, 95% CI 0.80-0.94). Vietnam veterans were at significantly greater risk of mortality from motor vehicle accidents than non-Vietnam veterans (ARR = 2.60, 95% CI 1.22-5.55) and this appeared to be specific to service in Vietnam based on comparisons to the U.S. population. Patterns did not differ greatly for the analysis on nurse veterans or to earlier mortality studies of these cohorts. CONCLUSION Mortality from motor vehicle accidents was significantly associated with service in Vietnam. Mortality patterns generally resembled those reported on in the past.
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Singh JA, Murdoch M. Effect of health-related quality of life on women and men's Veterans Affairs (VA) health care utilization and mortality. J Gen Intern Med 2007; 22:1260-7. [PMID: 17610020 PMCID: PMC2219767 DOI: 10.1007/s11606-007-0254-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2006] [Revised: 04/16/2007] [Accepted: 05/08/2007] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Although women will account for almost 11% of veterans by 2040, we know little about their health and functioning, particularly compared to men. OBJECTIVE To compare women and men veterans' health-related quality of life (HRQOL) and VA health care utilization and to see if previously described associations between HRQOL, subsequent VA health care utilization, and mortality in male veterans would generalize to women veterans. METHODS Prospective cohort study of all veterans who received medical care from an Upper Midwest Veterans Affairs facility between 10/1/96 and 3/31/98 and returned a mailed questionnaire. RESULTS Women's effective survey response rate was 52% (n = 1,500); men's, 58% (n = 35,000). In the following year, 9% of women and 12% of men had at least one hospitalization. One percent of women and 3% of men died in the post-survey year. After adjustment, women's HRQOL was higher than men's; for every 10-point decrement in overall physical or mental functioning, women and men had similarly increased risk/odds of subsequently dying, being hospitalized at a VA facility, or making a VA outpatient stop. Among younger women and women who received VA care outside of the Twin City metro area, poorer overall mental or physical health functioning was associated with fewer primary care stops; among their male counterparts, it was associated with more primary care stops. CONCLUSION Compared to men, women veterans receiving VA health care in the upper Midwest catchment area had better HRQOL and used fewer health services. Although VA health care utilization was similar across gender after adjusting for HRQOL, poorer mental or physical health was associated with fewer primary care stops for selected subgroups of women.
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Affiliation(s)
- Jasvinder A Singh
- Rheumatology Section, Minneapolis VA Medical Center, Minneapolis, MN, USA.
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Gackstetter GD, Hooper TI, DeBakey SF, Johnson A, Nagaraj BE, Heller JM, Kang HK. Fatal motor vehicle crashes among veterans of the 1991 Gulf War and exposure to munitions demolitions at Khamisiyah: a nested case-control study. Am J Ind Med 2006; 49:261-70. [PMID: 16550564 DOI: 10.1002/ajim.20280] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND A proposed explanation for the observed higher risk of fatal motor vehicle crashes (MVC) among 1991 Gulf War-deployed veterans is neurocognitive deficits resulting from nerve agent exposure at Khamisiyah, Iraq. Our objective was to assess any association between postwar fatal MVC and possible nerve agent exposure based on 2000 modeled plume data. METHODS Cases were defined as MVC deaths with a record in the Department of Transportation Fatality Analysis Reporting System through 1995. Cases (n = 282) and controls (n = 3,131) were derived from a larger nested case-control study of Gulf War-era veterans and limited to Army, male, deployed personnel. Exposure and cumulative dose by case-control status were analyzed using multivariate techniques. RESULTS Exposure status was not associated with fatal MVC (OR 0.96, 95% CI 0.72-1.26), nor were tertiles of cumulative dose. CONCLUSIONS Findings do not support an association between possible exposures at Khamisiyah and postwar fatal MVC among Gulf War veterans.
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Affiliation(s)
- Gary D Gackstetter
- Center for Force Health Protection Studies, Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814-4799, USA
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Goldzweig CL, Balekian TM, Rolón C, Yano EM, Shekelle PG. The state of women veterans' health research. Results of a systematic literature review. J Gen Intern Med 2006; 21 Suppl 3:S82-92. [PMID: 16637952 PMCID: PMC1513165 DOI: 10.1111/j.1525-1497.2006.00380.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Assess the state of women veterans' health research. DESIGN Systematic review of studies that pertained specifically to or included explicit information about women veterans. A narrative synthesis of studies in 4 domains/topics was conducted: Stress of military life; Health and performance of military/VA women; Health services research/quality of care; and Psychiatric conditions. MEASUREMENTS AND MAIN RESULTS We identified 182 studies. Of these, 2 were randomized-controlled trials (RCTs) and the remainder used observational designs. Forty-five percent of studies were VA funded. We identified 77 studies pertaining to the stress of military life, of which 21 reported on sexual harassment or assault. Rates of harassment ranged from 55% to 79% and rates of sexual assault from 4.2% to 7.3% in active duty military women and 11% to 48% among women veterans. Forty-two studies concerned the health and performance of military/VA women, with 21 studies evaluating sexual assault and posttraumatic stress disorder (PTSD) and their effect on health. Fifty-nine studies assessed various aspects of health services research. Eight studies assessed quality of care and 5, patient satisfaction. Twenty-five studies assessed utilization and health care organization, and findings include that women veterans use the VA less than men, that gender-specific reasons for seeking care were common among female military and veteran personnel, that provision of gender-specific care increased women veterans' use of VA, and that virtually all VAs have available on-site basic women's health services. Fifty studies were classified as psychiatric; 31 of these were about the risk, prevalence, and treatment of PTSD. CONCLUSIONS Most research on VA women's health is descriptive in nature and has concerned PTSD, sexual harassment and assault, the utilization and organization of care, and various psychiatric conditions. Experimental studies and studies of the quality of care are rare.
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Affiliation(s)
- Caroline L Goldzweig
- Southern California Evidence-Based Practice Center, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA.
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Abstract
Most of today's 1.7 million women veterans obtain all or most of their medical care outside the VA health care system, where their veteran status is rarely recognized or acknowledged. Several aspects of women's military service have been associated with adverse psychologic and physical outcomes, and failure to assess women's veteran status, their deployment status, and military trauma history could delay identifying or treating such conditions. Yet few clinicians know of women's military history--or of military service's impact on women's subsequent health and well being. Because an individual's military service may be best understood within the historical context in which it occurred, we provide a focused historical overview of women's military contributions and their steady integration into the Armed Forces since the War for Independence. We then describe some of the medical and psychiatric conditions associated with military service.
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Affiliation(s)
- Maureen Murdoch
- Section of General Internal Medicine, Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, Minneapolis, MN 55417, USA.
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Abstract
Although official data have reported an average number of suicides in the veterans of the Vietnam War, the veterans themselves estimate that the death toll from suicide may be 8 to 10 times the official toll. Attention is drawn to a website honoring those veterans of the war who have committed suicide: www.suicidewall.com
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Affiliation(s)
- David Lester
- Richard Stockton College of New Jersey, Blackwood, NJ 08012-5356, USA.
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Abstract
An increasing percentage of the US Armed Forces are women. Although barred from ground combat job titles, women are serving in ever-broader military occupations. Combat activity is widely dispersed in contemporary wars. involving rear echelon personnel and escalating the involvement of women in hostile action. War is associated with psychological trauma, deprivations, and toxic exposures, each potentially evoking profound long-lasting mental and physical health effects on soldiers. There is some evidence that the mental and physical health sequellae are different in women, although there remain many large gaps in our knowledge. These differences may be due to differing exposures and experiences or they may reflect different vulnerabilities. Health care providers caring for soldiers and veterans require accurate data regarding risks borne by the men and women who have experienced war. Needed are continued comprehensive studies of the health status of former war soldiers. These studies must be designed so that men and women can be compared in the context of specific roles and exposures. Debriefing activities are critical to providing early clues to soldiers' health problems. It is reasonable to anticipate that treatment responses may differ for men and women. Needed are broad follow-up studies in women and men to guide clinical care.Nursing education changes are needed. Because the violence and terror that characterize a war zone are not limited to that venue, there is need for systematic preparation of health care providers to care for patients during disaster and mass casualty situations. Health care providers, such as nurses,could benefit from learning strategies to protect their own health, as well,when confronted with mass casualties. Because the United States continues to send large numbers of its citizens to war, it is critical that nurses appreciate the long-term impact of war on the men and women who serve and explore strategies effective in restoring the war veteran's mental and physical health.
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Affiliation(s)
- Eleanor Frank Bond
- Department of Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, 1959 NE Pacific Street, Box 357266, Seattle WA 98195, USA.
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Hynes DM, Weaver F, Morrow M, Folk F, Winchester DJ, Mallard M, Ippolito D, Thakkar B, Henderson W, Khuri S, Daley J. Breast cancer surgery trends and outcomes: results from a national department of veterans affairs study. J Am Coll Surg 2004; 198:707-16. [PMID: 15110803 DOI: 10.1016/j.jamcollsurg.2004.01.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2003] [Accepted: 01/30/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND This study examined trends and outcomes for breast cancer surgery performed at Department of Veterans Affairs (VA) hospitals. STUDY DESIGN We examined breast cancer operations performed in VA hospitals from October 1991 to September 1997. Data from the VA National Surgical Quality Improvement Program, surgical pathology reports, discharge data, and outpatient data were used. Surgical outcomes included postoperative length of stay, 30-day morbidity rates, 1-year surgery-related readmission rates, and mortality. An expert panel of breast cancer clinicians identified surgery-related hospital readmissions. Hierarchical regression analysis was used to identify patient, provider, and hospital characteristics associated with postoperative length of stay, and 30-day morbidity. RESULTS From October 1991 to September 1997 1,333 breast operations were performed, ranging from 1 to 38 on average per hospital; 478 operations were for breast cancer. Among breast cancer surgery patients, 25% were men. Thirty-day morbidity rates, 1-year hospital readmission rates, and mortality were very low for both men and women. Postoperative length of stay averaged 6.8 days. Lower income, longer operation times, and older age increased the likelihood of 30-day morbidity. Lower functional status, older age, longer operation time, and lower average annual volume of procedures increased postoperative length of stay. Documentation of the extent of disease and surgical margin in pathology reports was poor in medical records. CONCLUSIONS Hospital stays were longer, and morbidity and readmission rates for patients having breast cancer operations at VA hospitals were comparable to those reported for private sector hospitals.
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Affiliation(s)
- Denise M Hynes
- Midwest Center for Health Services and Policy Research, VA Information Resource Center, Edward Hines Jr. VA Administration Hospital, PO Box 5000 (151V), Fifth & Roosevelt Roads, Building 1 Room C305, Hines, IL 60141-5000, USA
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Kang HK, Bullman TA, Macfarlane GJ, Gray GC. Mortality among US and UK veterans of the Persian Gulf War: a review. Occup Environ Med 2002; 59:794-9. [PMID: 12468744 PMCID: PMC1763601 DOI: 10.1136/oem.59.12.794] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Mortality data on Gulf War veterans was reviewed as a means of evaluating the long term consequences of the war. Studies were located from searches of Medline, Proceedings of the Conference on Federally Sponsored Gulf War Veterans' Illnesses Research, Proceedings of the American Public Health Association Annual Meetings, Annual Reports to Congress, and personal contacts with knowledgeable investigators. Data on study design, methods, and results were obtained from published studies of both US and UK veterans who served in the Persian Gulf. The methodology and results of studies are summarised and evaluated. Additional research recommendations based on reviewed studies are presented. It is concluded that in both US and UK studies, mortality from external causes was higher, while mortality from all illnesses was lower among Gulf War veterans in comparison to those of non-Gulf War veterans. Increased mortality from external causes is consistent with patterns of postwar mortality observed in veterans of previous wars. Further follow up of Gulf War veterans and their controls is warranted for evaluating the mortality risk from diseases with longer latency periods.
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Affiliation(s)
- H K Kang
- The Environmental Epidemiology Service, Department of Veterans Affairs, Washington, DC 20036, USA.
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Kang HK, Mahan CM, Lee KY, Magee CA, Selvin S. Prevalence of gynecologic cancers among female Vietnam veterans. J Occup Environ Med 2000; 42:1121-7. [PMID: 11094792 DOI: 10.1097/00043764-200011000-00018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The possibility of a gender-specific health problem associated with the Vietnam War has been a concern since the war. We targeted 4140 female Vietnam veterans and 4140 veteran controls to complete a structured telephone interview that included questions regarding any history of gynecologic cancer. As a measure of association between the risk of cancer and military service in Vietnam, odds ratios and 95% confidence intervals were calculated using multiple logistic regression models that yielded estimates of potential cofounders. Although 8% of Vietnam veterans and 7.1% of non-Vietnam veterans reported a history of gynecologic cancers, namely, breast, ovary, uterus, or cervix, the difference was not statistically significant either for the individual site or for the gynecologic cancers as a group. Female Vietnam veterans have not experienced a higher prevalence of gynecologic cancer in the 30 years since the conflict.
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Affiliation(s)
- H K Kang
- Department of Veterans Affairs, Veterans Health Administration, Washington, D.C. 20036-3406, USA
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Abstract
BACKGROUND Since the 1965-1975 Vietnam War, there has been persistent concern that women who served in the U.S. military in Vietnam may have experienced adverse pregnancy outcomes. METHODS We compared self-reported pregnancy outcomes for 4,140 women Vietnam veterans with those of 4,140 contemporary women veterans who were not deployed to Vietnam. As a measure of association, we calculated odds ratios (OR) and 95% confidence intervals (CI) using logistic regression adjusting for age at conception, race, education, military nursing status, smoking, drinking and other exposures during pregnancy. RESULTS There was no statistically significant association between military service in Vietnam and index pregnancies resulting in miscarriage or stillbirth, low birth weight, pre-term delivery, or infant death. The risk of having children with "moderate-to-severe" birth defects was significantly elevated among Vietnam veterans (adjusted OR = 1.46, 95% CI = 1.06-2.02). CONCLUSIONS The risk of birth defects among index children was significantly associated with mother's military service in Vietnam.
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Affiliation(s)
- H K Kang
- Environmental Epidemiology Service, Veterans Health Administration Department of Veterans Affairs, Washington, DC 20036-3406, USA.
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Abstract
BACKGROUND Armed forces personnel who served in the Gulf War report more current ill-health than those who were not deployed. There has been concern expressed that they may also experience higher mortality rates. METHODS A retrospective cohort study was done including all 53462 UK Gulf War veterans (Gulf cohort) and a comparison group equivalent in size of personnel who were not deployed but matched for age, sex, rank, service, and level of fitness (Era cohort). Individuals were identified on central registers of the Office for National Statistics and information on death among cohort subjects, including cause of death, obtained. Follow-up extended from April 1, 1991 (the end of the Gulf War) until March 31, 1999. FINDINGS There were 395 deaths among the Gulf cohort and 378 deaths amongst the Era cohort (mortality rate ratio [MRR] 1.05, 95% CI 0.91-1.21). Mortality from "external" causes was higher in the Gulf cohort (Gulf 254, Era 216; MRR 1.18 [0.98-1.42] while mortality from "disease-related" causes was lower (Gulf 122, Era 141; 0.87 [0.67-1.11]). The higher mortality rate from "external" causes in the Gulf cohort was principally due to higher mortality rates from accidents. There was, however, no excess of deaths recorded as suicide in the Gulf cohort. INTERPRETATION This follow-up of veterans of the Gulf war has shown, 8 years after the end of the conflict, that although they have experienced higher mortality rates than a comparison cohort, the excess mortality rate is very small and does not approach statistical significance. The excess is related mainly to accidents rather than disease, a pattern that is consistent both with US veterans of the Gulf war and veterans from other conflicts.
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Affiliation(s)
- G J Macfarlane
- Unit of Chronic Disease Epidemiology, School of Epidemiology and Health Sciences, University of Manchester, UK.
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Zwerling C, Torner JC, Clarke WR, Voelker MD, Doebbeling BN, Barrett DH, Merchant JA, Woolson RF, Schwartz DA. Self-reported postwar injuries among Gulf War veterans. Public Health Rep 2000; 115:346-9. [PMID: 11059428 PMCID: PMC1308575 DOI: 10.1093/phr/115.4.346] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE From September 1995 to May 1996, the authors conducted a telephone survey of Iowa military personnel who had served in the regular military or activated National Guard or Reserve during the Gulf War period. To assess the association between military service in a combat zone and subsequent traumatic injury requiring medical consultation, the authors analyzed veterans' interview responses. METHODS Using data from the larger survey, the authors compared rates of self-reported postwar injuries requiring medical consultation in a sample of Iowa Gulf War veterans to the rates in a sample of Iowa military personnel who served at the same time, but not in the Persian Gulf. RESULTS Of 3695 veterans, 605 (16%) reported a traumatic injury in the previous three months requiring medical consultation. Self-reported injuries were associated with service in the Persian Gulf (odds ratio 1.26; 95% confidence interval 1.02, 1.55). CONCLUSION This finding is consistent with the results of earlier studies of traumatic injury mortality rates among war veterans.
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Affiliation(s)
- C Zwerling
- Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City 52242, USA.
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Maercker A, Herrle J, Grimm I. Dresdener Bombennachtsopfer 50 Jahre danach: Eine Untersuchung patho- und salutogenetischer Variablen. ACTA ACUST UNITED AC 1999. [DOI: 10.1024//1011-6877.12.3.157] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Zusammenfassung: Eine Untersuchung Dresdener Bombennachtsopfer von Februar 1945 hatte zum Ziel, das heutige Ausmaß posttraumatischer Belastungsstörungen (PTB) sowie die traumabezogene persönliche Reifung zu untersuchen. Angenommen wurde, daß der Grad der damaligen Traumaexposition mit der heutigen PTB-Symptomatik und der persönlichen Reifung in direktem Zusammenhang steht, daß externale bzw. internale Kontrollüberzeugungen mit der heutigen PTB-Symptomatik bzw. dem Ausmaß persönlicher Reifung assoziiert sind und daß das Alter zum Zeitpunkt der Traumatisierung eine Rolle für die (pathogenen) Traumafolgen spielte. Die Untersuchung von N = 47 Personen (heutiger Alters-Range: 57-95 Jahre) ergab ein relativ niedriges PTB-Symptomausmaß. Das Symptomausmaß und die traumabedingte persönliche Reifung waren nicht systematisch assoziiert, korrelierten aber jeweils mit der Traumaexposition. Die externalen und internalen Kontrollüberzeugungen zeigten Mediator- bzw. Moderatoreffekte in Bezug auf die Kriteriumsvariablen. Die Annahmen zum Traumatisierungsalter konnten im wesentlichen belegt werden.
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Affiliation(s)
- Andreas Maercker
- Technische Universität Dresden, Fachrichtung Psychologie, Klinische Psychologie und Psychotherapie
| | - Johannes Herrle
- Technische Universität Dresden, Fachrichtung Psychologie, Klinische Psychologie und Psychotherapie
| | - Ingrid Grimm
- Technische Universität Dresden, Fachrichtung Psychologie, Klinische Psychologie und Psychotherapie
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Read JP, Stern AL, Wolfe J, Ouimette PC. Use of a screening instrument in women's health care: detecting relationships among victimization history, psychological distress, and medical complaints. Women Health 1997; 25:1-17. [PMID: 9273980 DOI: 10.1300/j013v25n03_01] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The interactive relationship between psychological distress and physical health is a particularly salient one for women. Routine screening for abuse history and current psychological disturbance is essential in providing comprehensive patient care. The present study examines the utility of a brief screening measure in detecting psychological factors in female patients at a primary care facility. Sixty-nine percent of 108 women screened at a women's health clinic reported a history of trauma and almost half (49%) reported having been sexually harassed. Women presenting to treatment for gynecological problems were more likely to be victims of sexual assault and were more likely to report a history of childhood sexual abuse. In addition, women seeking specialized health care also reported increased rates of stress. Relationships among victimization histories, substance use, and eating disturbances were also found. These data suggest the importance of assessing psychological disturbances and trauma histories as part of a comprehensive medical evaluation.
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Affiliation(s)
- J P Read
- University of Rhode Island, Department of Psychology, Kingston, USA
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