Posttraumatic stress disorder (PTSD) results from experiencing or witnessing traumatic, life-threatening events including combat-related experiences. The purpose of this study was to investigate the prevalence of PTSD symptoms and diagnosis, self-reported exposures, and functional health in a large cross-section of the U.S. military.
Methods.
This study used baseline Millennium Cohort data (July 2001 to June 2003) of 75,156 U.S. military members to assess the population-based prevalence of PTSD symptoms, self-reported exposures, and functional health as measured by the Medical Outcomes Study Short Form 36-Item Health Survey for Veterans (SF-36V).
Results.
PTSD diagnosis without current symptoms was reported by 953 respondents (1.2%, weighted), 1,490 respondents (2.1%, weighted) reported no diagnosis but reported PTSD symptoms, and 287 respondents (0.4%, weighted) reported diagnosis and current symptoms. Self-reported exposure to chemical or biological warfare agents, protective countermeasures, or hearing alarms were associated with PTSD symptoms independent of other combat-like exposures. Physical health was similar among those with PTSD diagnosis and current PTSD symptoms. However, compared with the overall cohort, lower mental health summary means for those reporting current PTSD symptoms (mean 5 27.8), current symptoms and diagnosis (mean = 24.6), and diagnosis without current symptoms (mean = 47.5) were found.
Conclusions.
Results suggest a 2.0% prevalence of PTSD symptoms without diagnosis and that self-reported threatening exposures were significantly associated with PTSD symptoms. Mental and physical health scores of those with current PTSD symptoms appear diminished, but suggest a return to cohort levels with resolution of PTSD symptoms.
References
1.
KulkaRASchlengerWEFairbankJAHoughRLJordanBKMar-MarCR, Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel; 1990.
2.
KangHKHyamsKC. Mental health care needs among recent war veterans. N Engl J Med2005;352:1289.
3.
KangHKNatelsonBHMahanCMLeeKYMurphyFM. Posttraumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: A population-based survey of 30,000 veterans. Am J Epidemiol2003;157:141–8.
4.
HogeCWCastroCAMesserSCMcGurkDCottingDIKoffmanRL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med2004;351:13–22.
5.
BremnerJDSouthwickSMDarnellACharneyDS. Chronic PTSD in Vietnam combat veterans: Course of illness and substance abuse. Am J Psychiatry1996;153:369–75.
6.
OrrSPPitmanRKLaskoNBHerzLR. Psychophysiological assessment of posttraumatic stress disorder imagery in World War II and Korean combat veterans. J Abnorm Psychol1993;102:152–9.
7.
FriedmanMJ. Veterans' mental health in the wake of war. N Engl J Med2005;352:1287–90.
8.
CardJJ. Epidemiology of PTSD in a national cohort of Vietnam veterans. J Clin Phychol1987;43:6–17.
9.
FoyDWSipprelleRCRuegerDBCarrollEM. Etiology of posttraumatic stress disorder in Vietnam veterans: Analysis of premilitary, military, and combat exposure influences. J Consult Clin Psychol1984;52:79–87.
10.
SmithTCRyanMAWingardDLSlymenDJSallisJFKritz-SilversteinD.New onset and persistent symptoms of post-traumatic stress disorder self-reported after deployment and combat exposures: Prospective population-based U.S. military cohort study. BMJ2008;336:366–71.
11.
GoenjianAKSteinbergAMNajarianLMFairbanksLATashjianMPynoosRS. Prospective study of posttraumatic stress, anxiety, and depressive reactions after earthquake and political violence. Am J Psychiatry2000;157:911–6.
12.
VergerPDabWLampingDLLozeJYDeschaseaux-VoinetCAbenhaimL, The psychological impact of terrorism: An epidemiologic study of posttraumatic stress disorder and associated factors in victims of the 1995–1996 bombings in France. Am J Psychiatry2004;161:1384–9.
13.
LatingJMShermanMFEverlyGSJrLowryJLPeragineTF. PTSD reactions and functioning of American Airlines flight attendants in the wake of September 11. J Nerv Ment Dis2004;192:435–41.
14.
RosenheckRFontanaA.Use of mental health services by veterans with PTSD after the terrorist attacks of September 11. Am J Psychiatry2003;160:1684–90.
15.
MaesMMylleJDelmeireLJancaA.Pre- and post-disaster negative life events in relation to the incidence and severity of post-traumatic stress disorder. Psychiatry Res2001;105:1–12.
16.
UrsanoRJFullertonCSKaoTCBhartiyaVR. Longitudinal assessment of posttraumatic stress disorder and depression after exposure to traumatic death. J Nerv Ment Dis1995;183:36–42.
17.
NishithPMechanicMBResickPA. Prior interpersonal trauma: The contribution to current PTSD symptoms in female rape victims. J Abnorm Psychol2000;109:20–5.
18.
DahlS.Acute response to rape—a PTSD variant. Acta Psychiatr Neurol Scand1989;355:56–62.
19.
BownesITO'GormanECSayersA.Assault characteristics and posttraumatic stress disorder in rape victims. Acta Psychiatr Neurol Scand1991;83:27–30.
20.
RothSNewmanEPelcovitzDvan der KolkBMandelFS. Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV Field Trial for Posttraumatic Stress Disorder. J Trauma Stress1997;10:539–55.
21.
StreetAEAriasI.Psychological abuse and posttraumatic stress disorder in battered women: Examining the roles of shame and guilt. Violence Vict2001;16:65–78.
22.
KesslerRCSonnegaABrometEHughesMNelsonCB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry1995;52:1048–60.
23.
RiddleJRBrownMSmithTCRitchieECBrixKARomanoJ.Chemical warfare and the Gulf War: A review of the impact on Gulf veterans' health. Mil Med2003;168:606–13.
24.
HyamsKCWignallFSRoswellR.War syndromes and their evaluation: From the U.S. Civil War to the Persian Gulf War. Ann Intern Med1996;125:398–405.
25.
KentsmithDK. Principles of battlefield psychiatry. Mil Med1986;151:89–96.
26.
Health status of Vietnam veterans. I. Psychosocial characteristics. The Centers for Disease Control Vietnam Experience Study. JAMA1988;259:2701–7.
27.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed.DSM-IV. Washington: American Psychiatric Association; 1994.
28.
BendorAGelkopfMSigalM.Insanity and war: The Gulf War and a psychiatric institution. Am J Psychother1993;47:424–42.
29.
RyanMASmithTCSmithBAmorosoPBoykoEJGrayGC, Millennium Cohort: Enrollment begins a 21-year contribution to understanding the impact of military service. J Clin Epidemiol2007;60:181–91.
30.
TurnbullGJ. A review of post-traumatic stress disorder. Part I: Historical development and classification. Injury1998;29:87–91.
31.
TurnbullGJ. A review of post-traumatic stress disorder. Part II: Treatment. Injury1998;29:169–75.
32.
JonesEHodgins-VermaasRMcCartneyHEverittBBeechCPoynterD, Post-combat syndromes from the Boer War to the Gulf War: A cluster analysis of their nature and attribution. BMJ2002;324:321–4.
33.
JonesEVermaasRHMcCartneyHBeechCPalmerIHyamsK, Flashbacks and post-traumatic stress disorder: The genesis of a 20th-century diagnosis. Br J Psychiatry2003;182:158–63.
34.
DavidsonJSmithRKudlerH.Validity and reliability of the DSM-III criteria for posttraumatic stress disorder. Experience with a structured interview. J Nerv Ment Dis1989;177:336–41.
35.
KuhneABaragaECzekalaJ.Completeness and internal consistency of DSM-III criteria for post-traumatic stress disorder. J Clin Psychol1988;44:717–22.
36.
BrettEASpitzerRLWilliamsJB. DSM-III-R criteria for posttraumatic stress disorder. Am J Psychiatry1988;145:1232–6.
37.
FeinsteinA.Posttraumatic stress disorder: A descriptive study supporting DSM-III-R criteria. Am J Psychiatry1989;146:665–6.
38.
SolomonSDCaninoGJ. Appropriateness of DSM-III-R criteria for posttraumatic stress disorder. Compr Psychiatry1990;31:227–37.
39.
MaesMDelmeireLSchotteCJancaACretenTMylleJ, Epidemiologic and phenomenological aspects of post-traumatic stress disorder: DSM-III-R diagnosis and diagnostic criteria not validated. Psychiatry Res1998;81:179–93.
40.
KinzieJDGoetzRR. A century of controversy surrounding posttraumatic stress-spectrum syndromes: The impact on DSM-III and DSM-IV. J Trauma Stress1996;9:159–79.
41.
WesselyS.Risk, psychiatry and the military. Br J Psychiatry2005;186:459–66.
42.
KingDWKingLAEricksonDJHuangMTSharkanskyEJWolfeJ.Posttraumatic stress disorder and retrospectively reported stressor exposure: A longitudinal prediction model. J Abnorm Psychol2000;109:624–33.
43.
EngdahlBESpeedNEberlyRESchwartzJ.Comorbidity of psychiatric disorders and personality profiles of American World War II prisoners of war. J Nerv Ment Dis1991;179:181–7.
44.
McFarlaneAC. The longitudinal course of posttraumatic morbidity. The range of outcomes and their predictors. J Nerv Ment Dis1988;176:30–9.
45.
McFarlaneAC. The prevalence and longitudinal course of PTSD. Implications for the neurobiological models of PTSD. Ann N Y Acad Sci1997;821:10–23.
46.
SolomonZMikulincerMWaysmanM.Delayed and immediate onset posttraumatic stress disorder. II. The role of battle experiences and personal resources. Soc Psychiatry Psychiatr Epidemiol1991;26:8–13.
47.
SolomonZMikulincerMWaysmanMMarloweDH. Delayed and immediate onset posttraumatic stress disorder. I. Differential clinical characteristics. Soc Psychiatry Psychiatr Epidemiol1991;26:1–7.
48.
PortCLEngdahlBFrazierP.A longitudinal and retrospective study of PTSD among older prisoners of war. Am J Psychiatry2001;158:1474–9.
49.
ThompsonWWGottesmanIIZalewskiC.Reconciling disparate prevalence rates of PTSD in large samples of U.S. male Vietnam veterans and their controls. BMC Psychiatry2006;6:19.
50.
WeathersFWLitzBTHermanDSHuskaJAKeaneTM. The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the Annual Meeting of International Society for Traumatic Stress Studies; 1993 Oct 6–10; San Antonio, Texas. Also available from: URL: http://www.pdhealth.mil/library/downloads/PCL_sychometrics.doc [cited 2006 Jul 10].
51.
BlanchardEBJones-AlexanderJBuckleyTCFornerisCA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther1996;34:669–73.
52.
WrightKMHuffmanAHAdlerABCastroCA. Psychological screening program overview. Mil Med2002;167:853–61.
53.
BrewinCR. Systematic review of screening instruments for adults at risk of PTSD. J Trauma Stress2005;18:53–62.
54.
SmithTCSmithBJacobsonIGCorbeilTERyanMA. Reliability of standard health assessment instruments in a large, population-based cohort study. Ann Epidemiol2007;17:525–32.
55.
WareJEKosinskiMGandekB.SF-36 health survey: Manual and interpretation guide. Lincoln (RI): Quality Metric Inc.; 2000.
56.
WareJEJrSherbourneCD. The MOS 36-Item Short-Form Health Survey (SF-36). I. Conceptual framework and item selection. Med Care1992;30:473–83.
57.
McHorneyCAWareJEJrRaczekAE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care1993;31:247–63.
58.
WareJEDaviesARBrookRH. Conceptualization and measurement of health for adults in the Health Insurance Study. Volume VI: Analysis of relationships among health status measures. Santa Monica (CA): The Rand Corporation; 1980.
59.
WareJEKosinskiMKellerSD. SF-36 physical and mental health summary scales: A user's manual. Boston: Health Assessment Lab; 1994.
60.
PerlinJKazisLESkinnerKRenXSLeeARogersWH, Health status and outcomes of veterans: Physical and mental component summary scores, Veterans SF-36, 1999 Large Health Survey of Veteran Enrollees. Executive report. Washington: Department of Veterans Affairs, Veteran's Health Administration, Office of Quality and Performance (US); 2000.
61.
EwingJA. Detecting alcoholism. The CAGE questionnaire. JAMA1984;252:1905–7.
62.
SAS Institute Inc.SAS: Version 9.1.3. Cary (NC): SAS Institute Inc.; 2004.
63.
StuartJAUrsanoRJFullertonCSWesselyS.Belief in exposure to chemical and biological agents in Persian Gulf War soldiers. J Nerv Ment Dis2008;196:122–7.
64.
DobieDJKivlahanDRMaynardCBushKRDavisTMBradleyKA. Posttraumatic stress disorder in female veterans: Association with self-reported health problems and functional impairment. Arch Intern Med2004;164:394–400.
65.
MagruderKMFruehBCKnappRGJohnsonMRVaughanJA3rdCarsonTC, PTSD symptoms, demographic characteristics, and functional status among veterans treated in VA primary care clinics. J Trauma Stress2004;17:293–301.
66.
WellsTSJacobsonIGSmithTCSpoonerCNSmithBReedRJ, Prior health care utilization as a potential determinant of enrollment in a 21-year prospective study, the Millennium Cohort Study. Eur J Epidemiol2008;23:79–87.
67.
SmithBLeardCASmithTCReedRJRyanMA. Anthrax vaccination in the Millennium Cohort; validation and measures of health. Am J Prev Med2007;32:347–53.
68.
LeardMannCASmithBSmithTCWellsTSRyanMA. Smallpox vaccination: Comparison of self-reported and electronic vaccine records in the Millennium Cohort Study. Hum Vaccin2007;3:245–51.
69.
SmithTCJacobsonIGSmithBHooperTIRyanMATeamFT. The occupational role of women in military service: Validation of occupation and prevalence of exposures in the Millennium Cohort Study. Int J Environ Health Res2007;17:271–84.
70.
SmithBWingardDLRyanMAMaceraCAPattersonTLSlymenDJ. U.S. military deployment during 2001–2006: Comparison of subjective and objective data sources in a large prospective health study. Ann Epidemiol2007;17:976–82.
71.
SmithBSmithTCGrayGCRyanMA. When epidemiology meets the Internet: Web-based surveys in the Millennium Cohort Study. Am J Epidemiol2007;166:1345–54.
72.
FruehBCElhaiJDGrubaughALMonnierJKashdanTBSauvageotJA, Documented combat exposure of U.S. veterans seeking treatment for combat-related post-traumatic stress disorder. Br J Psychiatry2005;186:467–72.
