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. Author manuscript; available in PMC: 2026 Jan 4.
Published in final edited form as: Ann Behav Med. 2025 Jan 4;59(1):kaaf095. doi: 10.1093/abm/kaaf095

Trauma, Posttraumatic Stress Disorder, and Incident Chronic Disease

Kyle J Bourassa 1,2, Livia Anderson 3, John C Brown 3, Paul A Dennis 3,4, Melanie E Garrett 5; VA Mid-Atlantic MIRECC Workgroup1, Allison E Ashley-Koch 5, Jean C Beckham 1,6, Nathan A Kimbrel 1,3,6
PMCID: PMC12695002  NIHMSID: NIHMS2121227  PMID: 41350112

Abstract

Background:

Posttraumatic stress disorder (PTSD) is associated with chronic disease risk, particularly cardiovascular disease (CVD). However, few studies have combined detailed measurements of trauma exposure and PTSD with incident chronic disease outcomes assessed using electronic health records (EHRs).

Purpose:

Our study examined associations between traumatic stress (combat exposure, lifetime trauma exposure, PTSD symptoms, and PTSD diagnosis) and chronic disease outcomes, including seven clinical risk factors and 11 major chronic disease diagnoses assessed using EHRs.

Methods:

Participants included 3,696 post-9/11 U.S. veterans enrolled in the VISN 6 MIRECC’s Post-Deployment Mental Health Study cohort who averaged 38.1 years old at baseline with 13.3 years of follow-up.

Results:

At baseline, greater PTSD symptoms were associated with higher body mass, more alcohol use, higher rates of smoking, hypertension, and hyperlipidemia. Over follow-up, veterans with more combat exposure (HR, 1.11; 95% CI, 1.04-1.19; p = .002), trauma exposure (HR, 1.15; 95% CI, 1.08-1.23; p < .001), PTSD symptoms (HR, 1.22; 95% CI, 1.14-1.30; p < .001), or a diagnosis of PTSD (HR, 1.39; 95% CI, 1.21-1.59; p < .001) developed more chronic disease. PTSD symptoms and diagnostic status showed consistent associations with incident onset of cardiovascular disease, diabetes, and pulmonary disease, and associations remained when accounting for non-PTSD psychiatric diagnoses. Compared to veterans with current PTSD, veterans with past PTSD had reduced risk of developing chronic diseases.

Conclusions:

Future research should examine if treating PTSD and the sequelae of trauma has the potential to reduce risk for chronic disease, particularly cardiovascular disease, diabetes, and pulmonary disease.

Keywords: Posttraumatic stress disorder, trauma, combat exposure, veterans, chronic disease

Introduction

People who experience trauma and develop posttraumatic stress disorder (PTSD) are at increased risk for poor health [1–9], including cardiovascular disease (CVD; [6–12]), metabolic disorders [5,13], and dementia [11,14–15]. Although many studies have linked traumatic stress to chronic disease risk [16–17], these studies have largely been cross-sectional, lacked detailed assessment of traumatic stress, or lacked chronic disease outcomes assessed in clinical settings [18]. Addressing these limitations requires linking measures of traumatic stress to chronic disease onset in disease-free individuals [18]. Doing so would build on studies using PTSD diagnoses derived from health records that were unable to include measures of trauma history or PTSD severity [19], such as recent work showing women veterans with PTSD are at risk of incident CVD [6]. Given the existence of behavioral and pharmacological treatments for PTSD, additional evidence that traumatic stress increases risk for chronic disease could support future work testing whether PTSD treatment might help prevent the onset of chronic disease.

In the current study, we sought to evaluate the associations between comprehensive assessments of traumatic stress and chronic diseases outcomes derived from Veteran’s Affairs (VA) electronic health records (EHRs) among 3,696 U.S. military veterans from the post-9/11 service era [20]. We hypothesized that higher levels of traumatic stress would be associated with worse clinical risk factors and greater risk for chronic disease. Assessments of combat, trauma, and PTSD symptoms were conducted using validated self-report measures, whereas PTSD was diagnosed using clinical interviews. Veterans averaged 38.1 years of age at baseline with 13.3 years of follow up. Most (n = 3,167; 85.7%) were free of major chronic disease at baseline. We examined associations between traumatic stress and 11 chronic diseases that have comprised a large proportion of annual mortality in the United States [21], including several CVDs, metabolic diseases, dementia, pulmonary disease, and cancer. We also examined incident chronic disease risk when accounting for clinical risk factors and other mental health diagnoses, as well as for veterans with past PTSD or a PTSD diagnosis ascertained using health records.

Methods

Participants and Study Design

Participants were enrolled in the Veterans Integrated Service Networks 6 (VISN 6) Mental Illness Research, Education, and Clinical Center (MIRECC) Post-Deployment Mental Health Study [20], a multi-site study of veterans who served in the post-9/11 period, from 2005 to 2016. The Durham, Richmond, W.G. Bill Hefner VA and Central Virginia VA Health Care Systems’ Institutional Review Boards approved the study protocol and all participants provided informed consent. Study methods and results are reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement for observational studies. Participants were included if they completed relevant baseline assessments and had VA EHR data, resulting in a sample of 3,696 veterans (eFigure 1).

Measures

Traumatic stress.

Four measures of traumatic stress were assessed at baseline, all of which have been productively used in this cohort in prior studies [20].

Combat exposure.

Combat exposure was assessed using the Combat Exposure Scale (CES; [22,20]), a 7-item self-report measure of wartime stressors experienced by combatants.

Trauma exposure.

Lifetime trauma exposure was assessed using the sum of 22 categories of self-reported traumatic events experienced on the Traumatic Life Events Questionnaire [23].

PTSD symptoms.

PTSD symptoms were assessed using the Davidson Trauma Scale [24–25], a 17-item self-report measure of the frequency and intensity of PTSD symptoms over the past week. This

PTSD diagnostic status.

PTSD diagnostic status was assessed using the Structured Clinical Interviews for DSM-IV [26] conducted by trained research personnel. If participants did not meet criteria for current PTSD, they were assessed to determine whether they met criteria for PTSD in the past. For 188 (5.1%) participants missing clinical interview data, PTSD symptoms scores were used to define PTSD status using a validated clinical cutoff [25] of 35 or greater on the Davidson Trauma Scale. In total, 1,222 (33.1%) veterans had interviewer-assessed PTSD, with an additional 358 (9.7%) veterans meeting criteria for past PTSD [27]. We also used an established algorithm [28] to generate an EHR-assessed measure of PTSD at study enrollment derived from ICD-9 (309.81) and ICD-10 (F43.10-12) codes. In total, 1,368 veterans (37.0%) met criteria for EHR-assessed PTSD.

Chronic disease.

Thirteen chronic disease diagnoses (hypertension, hyperlipidemia, myocardial infarction, stroke, heart failure, angina, peripheral vascular disease, diabetes, dementia, chronic pulmonary disease, cancer, liver disease, and renal disease) were ascertained using ICD-9 and ICD-10 codes [29] linked to VA outpatient, inpatient, and purchased care data (i.e., community care referrals from VA providers or paid by VA sources, eMethod 1). As veterans enrolled from 2005 to 2018 [20] with a censor date of 12/31/2024, follow-ups ranged from 7.0 to 19.5 years in length. For each chronic disease, records assessed whether veterans had a diagnosis at baseline, a new diagnosis over the follow-up, and time to diagnosis or censor date. Composite scores of major chronic disease (i.e., excluding hypertension and hyperlipidemia) were created for: 1) baseline chronic disease count, 2) time to any incident chronic disease, and 3) time to incident CVD (i.e., myocardial infarction, stroke, heart failure, angina, or peripheral vascular disease).

Clinical biomarkers.

Body mass, blood pressure, and pulse were assessed during VA clinical encounters. Baseline values used averages across a 2-year lookback period, and 5-year follow-up values averaged post-baseline values for years 4, 5, and 6 (see eMethod 1 for additional details).

Demographics.

Participants reported their age, sex, race, ethnicity, and years of education.

Smoking.

Participants reported if they never smoked, were a past smoker, or currently smoked.

Alcohol use.

Alcohol use was assessed using the Alcohol Use Disorders Identification Test [30], a 10-item self-report measure, with higher scores indicating greater alcohol use.

Other mental health disorders.

A count of mental health disorders was created using diagnoses from DSM-IV clinical interviews [26] for 16 non-PTSD mental health diagnoses (eMethod 1).

Data Analysis

We first examined the associations between the traumatic stress measures (combat exposure, lifetime trauma exposure, PTSD symptoms, and PTSD diagnosis) and baseline chronic disease count. We next examined associations with clinical risk factors: blood pressure, pulse rate, body mass, alcohol use, current smoking, hypertension, and hyperlipidemia. We then tested associations between the traumatic stress measures and incident chronic disease. Outcomes included two composite outcomes (any chronic disease, CVD) and each major chronic disease assessed independently. Additional models examined the association between traumatic stress and chronic disease when accounting for clinical risk factors, accounted for other mental health diagnoses, and tested differences in predicting disease onset based on lifetime PTSD history (i.e., no PTSD, past PTSD, current PTSD) and PTSD diagnosis method (interview or EHR). Models with count outcomes used negative binomial regression; models with continuous outcomes used linear regression, models with dichotomous outcomes used logistic regression; models testing disease onset used Cox proportional-hazard models. Models assessing continuous, count, or dichotomous outcomes accounted for missing data using full information maximum likelihood estimation. Survival models excluded individuals who already had the relevant chronic disease outcome at baseline. All model estimates were scaled to 1 SD of the traumatic stress measures, and adjusted for demographics (age, sex, race and ethnicity, and education), alcohol use, and smoking. For our primary models assessing clinical risk factors and chronic disease onset, we present whether models met nominal significance (α < 0.05), as well as significance after a Bonferroni correction for multiple testing. Secondary and sensitivity analyses present nominal significance only.

Results

The 3,696 veterans (2,863 men, 833 women) included 1,706 non-Hispanic Black veterans, 1,622 non-Hispanic White veterans, and 368 veterans with another race or ethnicity.

Traumatic Stress and Baseline Chronic Disease

At baseline, 3,167 veterans (85.7%) did not have a chronic disease—467 (12.6%) had one chronic disease and 62 (1.7%) had comorbid conditions. Veterans with more combat exposure (RR, 1.10; 95% CI, 1.01-1.20; p = .032), lifetime trauma exposure (RR, 1.25; 95% CI, 1.16-1.34; p < .001), PTSD symptoms (RR, 1.30; 95% CI, 1.21-1.41; p < .001), or a PTSD diagnosis (RR, 1.44; 95% CI, 1.22-1.71; p < .001) had more chronic disease at baseline.

Traumatic Stress and Clinical Risk Factors

At baseline, all four measures of traumatic stress were nominally associated with higher body mass, more alcohol use, and current smoking (Table 1), as well as the presence of hypertension and hyperlipidemia. Veterans with more PTSD symptoms or a PTSD diagnosis also had higher pulse rate. None of the traumatic stress measures were associated with baseline blood pressure or change in any clinical biomarker, with the exception that trauma exposure was nominally associated with increased pulse rate and PTSD diagnosis was associated with increase in BMI over time. PTSD symptoms and diagnosis were associated with new onset hypertension and hyperlipidemia, though only PTSD symptoms were significant when adjusting for multiple testing.

Table 1.

Association of traumatic stress measures and clinical risk factors

N = 3,696 Combat exposure Trauma exposure PTSD symptoms PTSD diagnosis
Baseline clinical risk factors β 95% CI p β 95% CI p β 95% CI p β 95% CI p
 Blood pressure  0.07 [−0.43, 0.56]  .793 −0.04 [−0.51, 0.43]  .878 0.12 [−0.35, 0.60]  .611 0.21 [−0.78, 1.20] .676
 Pulse 0.09 [−0.36, 0.54]  .703 0.55 [0.12, 0.98]  .012 1.13 [0.70, 1.56] <.001 * 1.32 [0.43, 2.22] .004
 Body mass 0.23 [0.03, 0.43] .022 0.37 [0.19, 0.56] <.001 * 0.46 [0.24, 0.63] <.001 * 0.43 [0.03, 0.82] .033
 Alcohol use 0.13 [0.10, 0.16] <.001 * 0.15 [0.12, 0.18] <.001 * 0.20 [0.17, 0.23] <.001 * 0.32 [0.25, 0.38] .001 *
OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p
 Current smoking 1.11 [1.02, 1.2] .014 1.17 [1.09, 1.27] <.001 * 1.30 [1.20, 1.40] <.001 * 1.58 [1.34, 1.85] .001 *
 Hypertension at baseline 1.10 [1.01, 1.21] .034 1.14 [1.05, 1.24]  .003 1.32 [1.21, 1.44] <.001 * 1.60 [1.34, 1.92] .001 *
 Hyperlipidemia at baseline 1.11 [1.01, 1.22] .033 1.17 [1.07, 1.27] <.001 * 1.34 [1.23, 1.47] <.001 * 1.37 [1.14, 1.65] .001 *
Change in clinical risk factors β 95% CI p β 95% CI p β 95% CI p β 95% CI p
 5-year change in blood pressure −0.03 [−0.40, 0.34] .887 −0.17 [−0.52, 0.18] .336 −0.11 [−0.46, 0.24] .543 −0.15 [−0.89, 0.59] .694
 5-year change in pulse 0.14 [−0.13, 0.42] .305 0.34 [0.08, 0.60] .010 0.24 [−0.03, 0.50] .079 0.42 [−0.12, 0.97] .129
 5-year change in body mass 0.04 [−0.08, 0.16] .546 −0.02 [−0.13, 0.10] .748 0.04 [−0.08, 0.15] .541 0.27 [0.04, 0.51] .022
HR 95% CI p HR 95% CI p HR 95% CI p HR 95% CI p
 Incident hypertension 1.13 [1.04, 1.22] .004 1.06 [0.99, 1.15] .111 1.14 [1.06, 1.23] <.001 * 1.22 [1.03, 1.44] .022
 Incident hyperlipidemia 1.04 [0.97, 1.12] .301 1.11 [1.04, 1.19] .003 1.14 [1.06, 1.22] <.001 * 1.25 [1.08, 1.46] .003
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Note: All models controlled for demographics (age, sex, race and ethnicity, and education), smoking status, and alcohol use, except those which assessed alcohol use or smoking, in which case those variables were modeled as outcomes. Clinical biomarker models used multiple regression, baseline diagnosis models used logistic regression, and new diagnosis models used Cox proportional hazard models. 5-year change in biomarker models controlled for baseline levels of each marker to create a residualized regression model of change. Biomarker values are not standardized and are reported in their original units, whereas Alcohol use is a standardized AUDIT score. Models include bolding to represent nominal significance (p < .05) and

*

to indicate significance when adjusting for multiple comparisons (p < .001). Cox proportional hazard models excluded individuals with the diagnosis at baseline.

CI = confidence interval; OR = odds ratio; HR = hazard ratio.

Traumatic Stress and Incident Chronic Disease

Over the follow up, veterans were at greater risk of developing a major chronic disease if they had more combat exposure (HR, 1.11; 95% CI, 1.04-1.19; p = .002), lifetime trauma exposure (HR, 1.15; 95% CI, 1.08-1.23; p < .001), PTSD symptoms (HR, 1.22; 95% CI, 1.14-1.30; p < .001), or a PTSD diagnosis (HR, 1.39; 95% CI, 1.21-1.59; p < .001; Figure 1).

Figure 1.

Figure 1.

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Survival curves illustrating the onset of any chronic disease for PTSD symptoms and diagnosis status. PTSD symptom groups represent quartile splits in the cohort, prior to excluding veterans with baseline disease.

Traumatic Stress and Incident Cardiovascular Disease

Over the follow up, veterans were at greater risk of developing a CVD if they had higher PTSD symptoms (HR, 1.30; 95% CI, 1.15-1.48; p < .001) or a PTSD diagnosis (HR, 1.57; 95% CI, 1.20-2.06; p < .001; Figure 2). The association of combat exposure and CVD onset met nominal significance (HR, 1.19; 95% CI, 1.04-1.36, p = .013; Table 2), and trauma exposure was not associated with CVD onset (HR, 1.09; 95% CI, 0.96-1.24, p = .194)

Figure 2.

Figure 2.

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Survival curves illustrating the onset of cardiovascular disease for PTSD symptoms and diagnoses. PTSD symptom groups represent quartile splits in the cohort, prior to excluding veterans with baseline disease.

Table 2.

Association of traumatic stress measures and chronic disease incidence among post-9/11 veterans

Chronic diseases Combat exposure Trauma exposure PTSD symptoms PTSD diagnosis
N = 3,696 Baseline Dx Dx Onset HR 95% CI p HR 95% CI p HR 95% CI p HR 95% CI p
Chronic disease categories
 Any chronic disease  n = 529  n = 954  1.10 [1.04, 1.19]  .002*  1.15 [1.08, 1.23] <.001 *  1.21 [1.14, 1.30] <.001 *  1.39 [1.21, 1.59] <.001 *
 Cardiovascular disease  n = 63  n = 228  1.19 [1.04, 1.36]  .013  1.09 [0.96, 1.24]  .194  1.30 [1.15, 1.48] <.001 *  1.57 [1.20, 2.06] <.001 *
Individual chronic diseases
 Myocardial infarction  n = 6  n = 55  1.16 [0.88, 1.52]  .291  1.31 [1.02, 1.68]  .037  1.33 [1.02, 1.72]  .033  1.74 [1.00, 3.00]  .049
 Stroke  n = 27  n = 86  1.20 [0.96, 1.49]  .106  1.17 [0.95, 1.44]  .133  1.41 [1.14, 1.73] <.001 *  1.74 [1.12, 2.67]  .013
 Heart failure  n = 14  n = 91  1.07 [0.86, 1.34]  .525  1.19 [0.98, 1.46]  .084  1.24 [1.01, 1.52]  .038  1.28 [0.83, 1.98]  .261
 Angina  n = 5  n = 44  1.27 [0.94, 1.71]  .124  1.17 [0.88, 1.57]  .280  1.50 [1.13, 2.00]  .005 2.56 [1.39, 4.68] <.001 *
 Peripheral vascular disease  n = 17  n = 27  1.51 [1.04, 2.21]  .032  0.80 [0.53, 1.20]  .277  1.46 [1.02, 2.10]  .038  1.73 [0.79, 3.77]  .170
 Diabetes  n = 36  n = 572  1.12 [1.03, 1.22]  .012  1.16 [1.07, 1.25] <.001 *  1.20 [1.10, 1.30] <.001 *  1.34 [1.12, 1.59] <.001 *
 Chronic pulmonary disease  n = 315  n = 269  1.15 [1.02, 1.31]  .025  1.22 [1.09, 1.37] <.001 *  1.32 [1.18, 1.49] <.001 *  1.66 [1.29, 2.13] <.001 *
 Dementia  n = 10  n = 21  1.44 [0.93, 2.23]  .107  0.93 [0.59, 1.46]  .733  1.23 [0.80, 1.90]  .340  1.39 [1.56, 3.46]  .474
 Cancer  n = 63  n = 107  1.03 [0.77, 1.27]  .774  1.04 [0.86, 1.27]  .661  1.02 [0.84, 1.25]  .825  1.10 [0.73, 1.67]  .655
 Liver disease  n = 37  n = 193  1.00 [0.86, 1.16]  .979  1.03 [0.89, 1.18]  .708  0.96 [0.83, 1.11]  .589  1.28 [0.84, 1.53]  .417
 Renal disease  n = 33  n = 159  0.93 [0.78, 1.10]  .391  0.97 [0.82, 1.13]  .674  1.08 [0.92, 1.27]  .363  1.09 [0.77, 1.52]  .637
Accounting for baseline clinical risk factors (total n = 2,763)
 Any chronic disease  n = 505  n = 759  1.06 [0.98, 1.14]  .132  1.14 [1.09, 1.17] .014  1.12 [1.04, 1.21] .003  1.22 [1.05, 1.42]  .008
 Cardiovascular disease  n = 61  n = 194  1.18 [1.02, 1.36]  .030  1.05 [0.91, 1.20] .543  1.23 [1.12, 1.40] .004  1.44 [1.08, 1.93]  .013
Accounting for other mental health diagnoses (total n = 3,505)
 Any chronic disease  n = 504  n = 899  1.10 [1.03, 1.18]  .007  1.13 [1.05, 1.20] <.001  1.17 [1.08, 1.26] <.001  1.27 [1.10, 1.48]  .002
Cardiovascular disease  n = 58  n = 217  1.14 [0.99, 1.32]  .062  1.06 [0.93, 1.21]  .398  1.19 [1.02, 1.39]  .023  1.37 [1.01, 1.84]  .041
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Note: All models controlled for baseline health, demographics (age, sex, race and ethnicity, and education), alcohol use, and smoking status. All models used Cox proportional hazard models and excluded participants with baseline chronic disease. Models assessing chronic disease categories and individual chronic diseases include bolding to represent nominal significance and

*

to indicate significance when adjusting for multiple comparisons (p < .006 for chronic disease categories, p < .001 for the individual chronic diseases). Models accounting for baseline clinical risk factors and other mental health diagnoses were smaller in total sample size due to missing clinical biomarker and mental health diagnostic data for some participants. The category of cardiovascular disease includes a diagnosis of myocardial infarction, stroke, heart failure, angina, or peripheral vascular disease.

CI = confidence interval; Dx = diagnosis, HR = hazard ratio.

Traumatic Stress and Specific Disease Onset

Veterans with higher PTSD symptoms or a PTSD diagnosis were at greater risk for a number of specific chronic diseases (Table 2), including several CVDs. Lifetime trauma exposure, PTSD symptoms, and PTSD diagnosis were associated with diabetes and chronic pulmonary disease. The measures of traumatic stress were not associated with cancer, renal disease, dementia, or liver disease.

Accounting for Baseline Clinical Risk Factors

Accounting for clinical risk factors at baseline partially attenuated associations between traumatic stress and the onset of any chronic disease and CVD (Table 2). However, PTSD symptoms and PTSD diagnosis remained associated with incident chronic disease and CVD when doing so. Pulse and body mass explained the majority of attenuated association with any chronic disease onset, whereas pulse, body mass, and smoking explained the majority of the attenuation in CVD onset.

Accounting for Other Mental Health Diagnoses

Accounting for non-PTSD mental health diagnoses partially attenuated associations with chronic disease and CVD onset, though PTSD symptoms and PTSD diagnosis remained associated with incident chronic disease and CVD (Table 2).

Including Measures of Traumatic Stress in the Same Model

We tested associations when including the traumatic stress measures in the same model. We first included combat exposure, trauma exposure, and PTSD symptoms in the same model, then combat exposure, lifetime trauma exposure, and PTSD diagnosis. Combat exposure was not associated with chronic disease across any models. Trauma exposure was associated with any chronic disease onset when included with the PTSD measures, but not CVD onset (eTable 1). PTSD symptoms and diagnosis were associated with chronic disease and CVD onset across all models.

Incident Chronic Disease in Veterans with Past PTSD

Compared to veterans with no lifetime PTSD, veterans who met criteria for PTSD in the past (n = 358) were more likely to have chronic disease at baseline (RR, 1.72; 95% CI, 1.35-2.19; p < .001), similar to veterans with current PTSD (RR, 1.62; 95% CI, 1.35-1.94; p < .001). Compared to veterans with no lifetime PTSD, veterans with past PTSD no more likely to develop chronic disease (HR, 1.15; 95% CI, 0.91-1.46; p = .243), and the magnitude of the association (Figure 3) was less than half of that for veterans with current PTSD (HR, 1.40; 95% CI, 1.21-1.62; p < .001). Veterans with past PTSD were not at greater risk of developing incident CVD compared to veterans with no history of PTSD (HR, 1.19; 95% CI, 0.73-1.94; p = .495), and the magnitude of the association was less than a third of that for veterans with current PTSD (HR, 1.63; 95% CI, 1.22-2.18; p < .001).

Figure 3.

Figure 3.

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Survival curves illustrating onset of any chronic disease and cardiovascular disease among veterans with current PTSD, PTSD in the past, and no lifetime history of PTSD.

Comparisons with PTSD Diagnoses Derived from EHR

Of the 1,222 veterans with interview-assessed PTSD, 901 (73.7%) also had an EHR-assessed PTSD diagnosis. Mean PTSD symptoms were roughly similar for veterans with a diagnosis exclusively by clinical interview or in the EHR, and veterans with a PTSD diagnosis assessed by both clinical interview and EHR had the highest self-reported PTSD symptoms (eFigure 2). This pattern was similar to that for associations with future chronic disease—veterans who had both interview- and EHR-assessed PTSD diagnoses showed the greatest risk of incident chronic disease and CVD (eFigure 3). Veterans with a PTSD diagnosis from only one method (clinical interview or EHR) had reduced risk for incident chronic disease compared to veterans with a diagnosis from both modalities (eTable 2), though their risk was broadly elevated compared to veterans without any PTSD diagnosis. Finally, PTSD symptoms were associated with chronic disease risk when accounting for EHR-assessed PTSD (eTable 3), suggesting that self-reported PTSD symptoms can help predict future health outcomes beyond EHR-derived PTSD status.

Sensitivity Analyses: Stratifying Results by Sex, Race and Ethnicity

Sex did not moderate the associations of any traumatic stress measure with chronic disease onset, though the association between combat and PTSD diagnosis with CVD was descriptively stronger for men veterans. Race and ethnicity did not moderate the associations of combat exposure, trauma, or PTSD diagnosis with any chronic disease onset, but did moderate the association for PTSD symptoms, such that the associations were attenuated for non-Hispanic Black veterans. Race and ethnicity also moderated the association of combat exposure, PTSD symptoms, and PTSD diagnosis with CVD onset, such that the associations were attenuated for non-Hispanic Black veterans (eTable 4).

Discussion

Using data from 3,696 post-9/11 veterans, we found that veterans with more traumatic stress, particularly PTSD, were more likely to have clinical risk factors at baseline and develop chronic disease over follow up. This included specific associations for PTSD symptoms and diagnostic status with incident onset of CVD, diabetes, and pulmonary disease among veterans who were free of disease at baseline. Across the majority of findings, associations with incident chronic disease were strongest for measures of PTSD compared to combat and trauma exposure. Notably, associations between PTSD and chronic disease onset remained when accounting for baseline clinical risk factors and other mental health diagnoses. We also found that individuals with past PTSD (i.e., met criteria for PTSD in the past) had reduced risk of developing future chronic disease and CVD compared to people with current PTSD.

Although numerous studies have shown trauma and PTSD are associated with increased risk for chronic disease [1–17], to our knowledge no prior studies have combined comprehensive assessment of multiple traumatic stress measures with chronic disease onset using medical records from an integrated healthcare system [18,19]. By doing so, our study adds important depth, breadth, and rigor to the existing literature. Using multiple measures of trauma and PTSD severity, for example, provides important depth by allowing for direct comparisons of the strengths of associations with incident chronic disease. The comparisons between interview- and EHR-assessed PTSD are particularly notable. We found that lifetime trauma and PTSD symptoms were associated with chronic disease even when accounting for EHR-assessed PTSD, which demonstrates that these measures have utility in predicting future disease beyond diagnostic data derived exclusively from ICD codes. In terms of breadth, we modeled associations with the onset of 11 major chronic diseases linked to the majority of deaths in the United States each year [21]. Many existing studies of PTSD have focused on only one chronic disease or disease category. Although there is great value in specificity, particularly when investigating disease pathogenesis [7], it is equally important to provide a broad picture of the different chronic diseases that might be associated with traumatic stress.

Finally, this work provides rigor that adds to existing studies of PTSD and health by testing models accounting for other mental health diagnoses and clinical risk factors. We found that the association between PTSD and incident chronic disease was not explained by other mental health disorders, providing empirical support for a specific link between PTSD and poor health beyond psychiatric disorders broadly. We also found that veterans with more PTSD symptoms had higher pulse, higher body mass, more problematic drinking, were more likely to currently smoke, and more likely to have a diagnosis of hypertension or hyperlipidemia, in line with prior studies [6–7; 31–32]. These risk factors attenuated a portion of the association between PTSD and chronic disease, largely due to higher levels of body mass, pulse rate, and current smoking. These results point to “determinants of determinants [18]” that could be the focus of future mechanistic studies or intervention efforts.

The pattern of associations between PTSD and individual chronic diseases were also notable. For example, veterans with PTSD were at greatly increased risk of cardiovascular events (stroke, 74%; myocardial infarction, 74%), chronic pulmonary disease (66%), and diabetes (34%). There were no observed associations with cancer, dementia, kidney disease, or liver disease. This was somewhat surprising given that veterans with PTSD in this cohort were more likely to smoke and had higher rates of problematic drinking; however, it is important to note that the relatively younger age of the cohort may have influenced the strengths of associations for individual diseases. These results may change as the cohort enters older age, highlighting the need for studies of age-related chronic diseases (e.g., dementia) in veterans with PTSD.

This work highlights the importance of conducting randomized clinical trials (RCTs) to test whether PTSD treatment can reduce risk for future chronic disease experimentally. Prior studies have shown PTSD treatment is associated with improved cardiovascular functioning [33–35] and can lower risk for hypertension [36], but evidence linking PTSD treatment to disease outcomes in RCTs is limited. Successful trials would provide evidence that risk for chronic diseases associated with PTSD can be reversed experimentally, which could provide motivation for individuals with PTSD to seek out and complete mental health treatment [37]. Indeed, some individuals with PTSD may not view a reduction of PTSD symptoms as a motivating outcome, but could instead value improvement in their physical health. RCTs that include mechanisms of action could also identify what health relevant behaviors change in response to treatment and improve health [38]. Eventual effectiveness studies could provide data indexing the cost of PTSD treatment to the savings of preventing costly acute medical events (e.g., myocardial infarction, stroke) or chronic disease onset (e.g., diabetes, chronic pulmonary disease). Although there are efficacious treatments for PTSD, it is also true that many people do not receive these treatments [37]. Strong evidence for the cost-effectiveness of PTSD treatment has the potential to support access to care by increasing justification for the reimbursement of mental health treatment.

The results of the current study should be interpreted within the context of several limitations. First, our EHR-derived outcomes can only capture data from VA sources. Although these data include diagnoses for community care accessed through the VA, it is possible that these results will not generalize to veterans who have not received any care from VA sources, veterans from other periods of military service, or civilian populations. Similarly, although we used a validated algorithm to ascertain PTSD diagnostic from EHRs, this algorithm only focused on ICD codes. Future studies could benefit from other approaches to defining PTSD using medical records [39]. Second, our results are observational and cannot determine whether PTSD is causally associated with chronic disease onset, which would require RCTs or other experimental designs [38]. Third, the rate of PTSD was higher in this military veteran sample than the general population [40], and associations in this sample may not generalize in populations with lower prevalence of PTSD. Similarly, the characteristics of this sample may not match that of other veterans or non-veterans, and this work should be replicated in other cohorts, particularly cohorts of older veterans who might have higher rates of age-related chronic disease onset.

Conclusions

Among 3,696 post-9/11 veterans, we found that combat exposure, lifetime trauma exposure, PTSD symptoms, and a diagnosis of PTSD increased risk for incident chronic disease. Associations were stronger for measures of PTSD than for lifetime trauma exposure or combat exposure and were largely explained by associations with CVD, pulmonary disease, and diabetes. Our results provide additional breadth and depth to prior studies linking PTSD to chronic disease risk by combining comprehensive measurement of traumatic stress, assessing multiple clinical risk factors, and ascertaining chronic disease outcomes via health records from an integrated healthcare system. These findings provide rigorous evidence that trauma and PTSD are associated with increased risk for incident chronic disease and highlight the need to conduct RCTs testing whether PTSD treatment reduces future disease risk.

Supplementary Material

1

Acknowledgements:

Conflicts of interest and sources of funding—No authors have conflicts of interest to report. This work was supported by Award #IK2CX002694 to Dr. Bourassa from the Clinical Science Research and Development (CSR&D) Service, a Research Career Scientist Award (#IK6BX006523) from the Biomedical Laboratory Research and Development (BLRD) Service to Dr. Kimbrel, and a Senior Research Career Scientist Award (#lK6BX003777) from CSR&D to Dr. Beckham of VA ORD. The funders/sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the VA, the U.S. government or any other affiliated institution. The VA Mid-Atlantic MIRECC Workgroup contributors include: Patrick S. Calhoun, PhD, Eric Dedert, PhD, Eric B. Elbogen, PhD, Robin A. Hurley, MD, Jason D. Kilts, PhD, Angela Kirby, MS, Scott D. McDonald, PhD, Sarah L. Martindale, Ph.D, Christine E. Marx, MD, MS, Scott D. Moore, MD, PhD, Rajendra A. Morey, MD, MS, Jennifer C. Naylor, PhD, Jared A. Rowland, PhD, Robert D. Shura, PsyD, Cindy Swinkels, PhD, H. Ryan Wagner, PhD.

Transparency statement:

This study and analyses were not preregistered. Data from the Post Deployment Mental Health (PDMH) Study are part of a Veterans Affairs data repository and are available to researchers who request access through the VISN 6 MIRECC and follow the appropriate data access protocols. Medical record data from the Veteran Affairs Corporate Data Warehouse are available to researchers who request and are approved for access through the Office of Research and Development (ORD) Data Access Request Tracker (DART). Materials are available by request from the VISN 6 MIRECC. Analytic code is available on request from the corresponding author.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1
NIHMS2121227-supplement-1.pdf (373.5KB, pdf)

Data Availability Statement

This study and analyses were not preregistered. Data from the Post Deployment Mental Health (PDMH) Study are part of a Veterans Affairs data repository and are available to researchers who request access through the VISN 6 MIRECC and follow the appropriate data access protocols. Medical record data from the Veteran Affairs Corporate Data Warehouse are available to researchers who request and are approved for access through the Office of Research and Development (ORD) Data Access Request Tracker (DART). Materials are available by request from the VISN 6 MIRECC. Analytic code is available on request from the corresponding author.

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