Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
BMC Psychiatry
Published in: BMC Psychiatry 1/2018

Open Access 01-12-2018 | Research article

Factors associated with persistent posttraumatic stress disorder among U.S. military service members and veterans

Authors: Richard F. Armenta, Toni Rush, Cynthia A. LeardMann, Jeffrey Millegan, Adam Cooper, Charles W. Hoge, for the Millennium Cohort Study team

Published in: BMC Psychiatry | Issue 1/2018

Login to get access

Abstract

Background

Posttraumatic stress disorder (PTSD) can have long-term and far-reaching impacts on health and social and occupational functioning. This study examined factors associated with persistent PTSD among U.S. service members and veterans.

Methods

Using baseline and follow-up (2001–2013) questionnaire data collected approximately every 3 years from the Millennium Cohort Study, multivariable logistic regression was conducted to determine factors associated with persistent PTSD. Participants included those who screened positive for PTSD using the PTSD Checklist–Civilian Version at baseline (N = 2409). Participants were classified as having remitted or persistent PTSD based on screening negative or positive, respectively, at follow-up.

Results

Almost half of participants (N = 1132; 47%) met criteria for persistent PTSD at the first follow-up; of those, 804 (71%) also screened positive for PTSD at the second follow-up. Multiple factors were independently associated with persistent PTSD in an adjusted model at the first follow-up, including older age, deployment with high combat exposure, enlisted rank, initial PTSD severity, depression, history of physical assault, disabling injury/illness, and somatic symptoms. Among those with persistent PTSD at the first follow-up, additional factors of less sleep, separation from the military, and lack of social support were associated with persistent PTSD at the second follow-up.

Conclusions

Combat experiences and PTSD severity were the most salient risk factors for persistent PTSD. Comorbid conditions, including injury/illness, somatic symptoms, and sleep problems, also played a significant role and should be addressed during treatment. The high percentage of participants with persistent PTSD supports the need for more comprehensive and accessible treatment, especially after separation from the military.
Literature
1.
Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351(1):13–22.CrossRefPubMed
2.
Kok BC, Herrell RK, Thomas JL, Hoge CW. Posttraumatic stress disorder associated with combat service in Iraq or Afghanistan: reconciling prevalence differences between studies. J Nerv Ment Dis. 2012;200(5):444–50.CrossRefPubMed
3.
Armed Forces Health Surveillance Center (AFHSC). Summary of mental disorder hospitalizations, active and reserve components, U.S. armed forces, 2000–2012. MSMR. 2013;20(7):4–11. discussion 10-11
4.
Vasterling JJ, Aslan M, Proctor SP, Ko J, Marx BP, Jakupcak M, Schnurr PP, Gleason T, Huang GD, Concato J. Longitudinal examination of posttraumatic stress disorder as a long-term outcome of Iraq war deployment. Am J Epidemiol. 2016;184:796–805.CrossRefPubMed
5.
Doron-LaMarca S, Niles BL, King DW, King LA, Pless Kaiser A, Lyons MJ. Temporal associations among chronic PTSD symptoms in US combat veterans. J Trauma Stress. 2015;28(5):410–7.CrossRefPubMed
6.
Marmar CR, Schlenger W, Henn-Haase C, Qian M, Purchia E, Li M, Corry N, Williams CS, Ho C-L, Horesh D. Course of posttraumatic stress disorder 40 years after the Vietnam war: findings from the National Vietnam Veterans Longitudinal Study. JAMA Psychiatry. 2015;72(9):875–81.CrossRefPubMed
7.
O'Toole BI, Catts SV, Outram S, Pierse KR, Cockburn J. The physical and mental health of Australian Vietnam veterans 3 decades after the war and its relation to military service, combat, and post-traumatic stress disorder. Am J Epidemiol. 2009;170(3):318–30.CrossRefPubMed
8.
Heim C, Nemeroff CB. Neurobiology of posttraumatic stress disorder. CNS Spectr. 2009;14(1):13–24.PubMed
9.
Asnaani A, Reddy MK, Shea MT. The impact of PTSD symptoms on physical and mental health functioning in returning veterans. J Anxiety Disord. 2014;28(3):310–7.CrossRefPubMed
10.
Goldberg J, Magruder KM, Forsberg CW, Kazis LE, Üstün TB, Friedman MJ, Litz BT, Vaccarino V, Heagerty PJ, Gleason TC. The association of PTSD with physical and mental health functioning and disability (VA cooperative study# 569: the course and consequences of posttraumatic stress disorder in Vietnam-era veteran twins). Qual Life Res. 2014;23(5):1579–91.CrossRefPubMed
11.
Sherin JE, Nemeroff CB. Post-traumatic stress disorder: the neurobiological impact of psychological trauma. Dialogues Clin Neurosci. 2011;13(3):263–78.PubMedPubMedCentral
12.
13.
Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. Am J Psychiatry. 2007;164(1):150–3.CrossRefPubMed
14.
Pacella ML, Hruska B, Delahanty DL. The physical health consequences of PTSD and PTSD symptoms: a meta-analytic review. J Anxiety Disord. 2013;27(1):33–46.CrossRefPubMed
15.
Beristianos MH, Yaffe K, Cohen B, Byers AL. PTSD and risk of incident cardiovascular disease in aging veterans. Am J Geriatr Psychiatry. 2016;24(3):192–200.CrossRefPubMed
16.
LeardMann CA, Woodall KA, Littman AJ, Jacobson IG, Boyko EJ, Smith B, Wells TS, Crum-Cianflone NF. Post-traumatic stress disorder predicts future weight change in the millennium cohort study. Obesity. 2015;23(4):886–92.CrossRefPubMed
17.
Gupta MA. Review of somatic symptoms in post-traumatic stress disorder. Int Rev Psychiatry. 2013;25(1):86–99.CrossRefPubMed
18.
Santiago PN, Wilk JE, Milliken CS, Castro CA, Engel CC, Hoge CW. Screening for alcohol misuse and alcohol-related behaviors among combat veterans. Psychiatr Serv. 2010;61(6):575–81.CrossRefPubMed
19.
Oquendo MA, Friend JM, Halberstam B, Brodsky BS, Burke AK, Grunebaum MF, Malone KM, Mann JJ. Association of comorbid posttraumatic stress disorder and major depression with greater risk for suicidal behavior. Am J Psychiat. 2003;160(3):580–2.CrossRefPubMed
20.
Allen ES, Rhoades GK, Stanley SM, Markman HJ. Hitting home: relationships between recent deployment, posttraumatic stress symptoms, and marital functioning for Army couples. J Fam Psychol. 2010;24(3):280–8.CrossRefPubMedPubMedCentral
21.
Lim D, Sanderson K, Andrews G. Lost productivity among full-time workers with mental disorders. J Ment Health Policy Econ. 2000;3(3):139–46.CrossRefPubMed
22.
McEwen BS. Central effects of stress hormones in health and disease: understanding the protective and damaging effects of stress and stress mediators. Eur J Pharmacol. 2008;583(2–3):174–85.CrossRefPubMedPubMedCentral
23.
Green BL, Grace MC, Lindy JD, Gleser GC, Leonard A. Risk factors for PTSD and other diagnoses in a general sample of Vietnam veterans. Am J Psychiatry. 1990;147(6):729–33.CrossRefPubMed
24.
Koenen KC, Stellman JM, Stellman SD, Sommer JF Jr. Risk factors for course of posttraumatic stress disorder among Vietnam veterans: a 14-year follow-up of American legionnaires. J Consult Clin Psychol. 2003;71(6):980–6.CrossRefPubMed
25.
Roy-Byrne P, Arguelles L, Vitek ME, Goldberg J, Keane TM, True WR, Pitman RK. Persistence and change of PTSD symptomatology--a longitudinal co-twin control analysis of the Vietnam era twin registry. Soc Psychiatry Psychiatr Epidemiol. 2004;39(9):681–5.CrossRefPubMed
26.
Jankowski MK, Schnurr PP, Adams GA, Green BL, Ford JD, Friedman MJ. A mediational model of PTSD in world war II veterans exposed to mustard gas. J Trauma Stress. 2004;17(4):303–10.CrossRefPubMed
27.
Rona RJ, Jones M, Sundin J, Goodwin L, Hull L, Wessely S, Fear NT. Predicting persistent posttraumatic stress disorder (PTSD) in UK military personnel who served in Iraq: a longitudinal study. J Psychiatr Res. 2012;46(9):1191–8.CrossRefPubMed
28.
Ryan MA, Smith TC, Smith B, Amoroso P, Boyko EJ, Gray GC, Gackstetter GD, Riddle JR, Wells TS, Gumbs G, et al. Millennium cohort: enrollment begins a 21-year contribution to understanding the impact of military service. J Clin Epidemiol. 2007;60(2):181–91.CrossRefPubMed
29.
Gray GC, Chesbrough KB, Ryan MA, Amoroso P, Boyko EJ, Gackstetter GD, Hooper TI, Riddle JR. The millennium cohort study: a 21-year prospective cohort study of 140,000 military personnel. Mil Med. 2002;167(6):483–8.PubMed
30.
Weathers F, Litz B, Herman D, Huska JA, Keane T. The PTSD checklist (PCL): reliability, validity, and diagnostic utility. San Antonio: Paper presented at: Annual Meeting of International Society for Traumatic Stress Studies; 1993.
31.
Terhakopian A, Sinaii N, Engel CC, Schnurr PP, Hoge CW. Estimating population prevalence of posttraumatic stress disorder: an example using the PTSD checklist. J Trauma Stress. 2008;21(3):290–300.CrossRefPubMed
32.
Hoge CW. Neuropsychiatric illnesses in war veterans. In: FA KDL, Hauser SL, Longo DL, Jameson JL, Loscaizo J, editors. Harrisons textbook of medicine. 19th ed. New York: McGraw Hill; 2015.
33.
Kroenke K, Strine TW, Spitzer RL, Williams JB, Berry JT, Mokdad AH. The PHQ-8 as a measure of current depression in the general population. J Affect Disord. 2009;114(1–3):163–73.CrossRefPubMed
34.
Kazis LE, Lee A, Spiro Iii A, Rogers W. Measurement comparisons of the medical outcomes study and veterans SF-36® health survey. Health Care Financ Rev. 2004;25(4):43.PubMedPubMedCentral
35.
LeardMann CA, Smith TC, Smith B, Wells TS, Ryan MA. Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: prospective US military cohort study. BMJ. 2009;338:b1273.CrossRefPubMedPubMedCentral
36.
Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64(2):258–66.CrossRefPubMed
37.
Jacobson IG, Ryan MA, Hooper TI, Smith TC, Amoroso PJ, Boyko EJ, Gackstetter GD, Wells TS, Bell NS. Alcohol use and alcohol-related problems before and after military combat deployment. JAMA. 2008;300(6):663–75.CrossRefPubMedPubMedCentral
38.
Maldonado G, Greenland S. Simulation study of confounder-selection strategies. Am J Epidemiol. 1993;138(11):923–36.CrossRefPubMed
39.
Mickey RM, Greenland S. The impact of confounder selection criteria on effect estimation. Am J Epidemiol. 1989;129(1):125–37.CrossRefPubMed
40.
41.
Xue C, Ge Y, Tang B, Liu Y, Kang P, Wang M, Zhang L. A meta-analysis of risk factors for combat-related PTSD among military personnel and veterans. PLoS One. 2015;10(3):e0120270.CrossRefPubMedPubMedCentral
42.
Prigerson HG, Maciejewski PK, Rosenheck RA. Combat trauma: trauma with highest risk of delayed onset and unresolved posttraumatic stress disorder symptoms, unemployment, and abuse among men. J Nerv Ment Dis. 2001;189(2):99–108.CrossRefPubMed
43.
Larson GE, Highfill-McRoy RM, Booth-Kewley S. Psychiatric diagnoses in historic and contemporary military cohorts: combat deployment and the healthy warrior effect. Am J Epidemiol. 2008;167(11):1269–76.CrossRefPubMed
44.
Yehuda R, Hoge CW, McFarlane AC, Vermetten E, Lanius RA, Nievergelt CM, Hobfoll SE, Koenen KC, Neylan TC, Hyman SE. Post-traumatic stress disorder. Nat Rev Dis Primers. 2015;1:15057.CrossRefPubMed
45.
Gehrman P, Seelig AD, Jacobson IG, Boyko EJ, Hooper TI, Gackstetter GD, Ulmer CS, Smith TC. Predeployment sleep duration and insomnia symptoms as risk factors for new-onset mental health disorders following military deployment. In: DTIC Document; 2013.
46.
Krystal JH, Pietrzak RH, Rosenheck RA, Cramer JA, Vessicchio J, Jones KM, Huang GD, Vertrees JE, Collins J, Krystal AD. Sleep disturbance in chronic military-related PTSD: clinical impact and response to adjunctive Risperidone in the veterans affairs cooperative study# 504. J Clin Psychiatry. 2016;77(4):483–91.CrossRefPubMed
47.
Han SC, Castro F, Lee LO, Charney ME, Marx BP, Brailey K, Proctor SP, Vasterling JJ. Military unit support, postdeployment social support, and PTSD symptoms among active duty and National Guard soldiers deployed to Iraq. J Anxiety Disord. 2014;28(5):446–53.CrossRefPubMed
48.
Creamer M, Carboon I, Forbes AB, McKenzie DP, McFarlane AC, Kelsall HL, Sim MR. Psychiatric disorder and separation from military service: a 10-year retrospective study. Am J Psychiat. 2006;163:733–4.CrossRefPubMed
49.
Schnurr PP, Lunney CA, Sengupta A, Waelde LC. A descriptive analysis of PTSD chronicity in Vietnam veterans. J Trauma Stress. 2003;16(6):545–53.CrossRefPubMed
50.
Millegan J, Milburn EK, LeardMann CA, Street AE, Williams D, Trone DW, Crum-Cianflone NF. Recent sexual trauma and adverse health and occupational outcomes among US Service women. J Trauma Stress. 2015;28(4):298–306.CrossRefPubMed
51.
Millegan J, Wang L, LeardMann CA, Miletich D, Street AE. Sexual trauma and adverse health and occupational outcomes among men serving in the US military. J Trauma Stress. 2016;29:132–40.CrossRefPubMed
52.
Smith B, Wingard DL, Ryan MA, Macera CA, Patterson TL, Slymen DJ. U.S. military deployment during 2001-2006: comparison of subjective and objective data sources in a large prospective health study. Ann Epidemiol. 2007;17(12):976–82.CrossRefPubMed
53.
Wells TS, Jacobson IG, Smith TC, Spooner CN, Smith B, Reed RJ, Amoroso PJ, Ryan MA. Prior health care utilization as a potential determinant of enrollment in a 21-year prospective study, the millennium cohort study. Eur J Epidemiol. 2008;23(2):79–87.CrossRefPubMed
Metadata
Title
Factors associated with persistent posttraumatic stress disorder among U.S. military service members and veterans
Authors
Richard F. Armenta
Toni Rush
Cynthia A. LeardMann
Jeffrey Millegan
Adam Cooper
Charles W. Hoge
for the Millennium Cohort Study team
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Psychiatry / Issue 1/2018
Electronic ISSN: 1471-244X
DOI
https://doi.org/10.1186/s12888-018-1590-5

Other articles of this Issue 1/2018

BMC Psychiatry 1/2018 Go to the issue

Research article

The prevalence of metabolic syndrome in patients receiving antipsychotics in Qatar: a cross sectional comparative study

Study protocol

Prevention of violent revictimization in depressed patients with an add-on internet-based emotion regulation training (iERT): study protocol for a multicenter randomized controlled trial

Research article

Body image in patients with somatoform disorder

Research article

Understanding geographic variations in psychiatric inpatient admission rates: width of the variations and associations with the supply of health and social care in France

Research article

ADHD medication in offspring of immigrants — does the income level of the country of parental origin matter?

Research article

Borderline personality symptoms and work performance: a population-based survey