AIMS:Posttraumatic stress disorder (PTSD) is associated with type 2 diabetes (T2D). However, no studies have determined if risk for adverse T2D outcomes vary among different PTSD comorbidity patterns. METHODS:We identified 152,171 Veterans Health Administration (VHA) patients with de-identified medical records who had comorbid PTSD and T2D. All had adequate HbA1c control, not on insulin, and were free of microvascular and macrovascular complications at index. Latent class analyses (LCA) identified 3 comorbidity profiles characterized as depression + anxiety; high comorbidity; and low comorbidity. We then estimated the link between comorbidity classes and risk for adverse T2D outcomes and all-cause mortality. RESULTS:Most (64.4%) of the sample was ≥ 60 years of age, male (90.9%), and White race (69.1%). High comorbidity vs. low comorbidity and depression + anxiety vs. low comorbidity were associated with all-cause mortality (HR = 1.39; 95%CI:1.28-1.50 and HR = 1.18;95%CI:1.14-1.23, respectively). The depression + anxiety vs. the low comorbidity class, had slightly worse glycemic control (HR = 1.04; 95%CI:1.02-1.06) and microvascular complications (HR = 1.04; 95%CI:1.02-1.06). CONCLUSIONS:More psychiatric comorbidity in patients with PTSD is associated with worse glycemic control, increased risk for T2D micro- and macro- complications, and mortality. Research is needed to determine if treatment and improvement in patients with comorbid psychiatric disorders leads to improved T2D outcomes.

This study aimed to investigate associations between social determinants of health (SDoH, the conditions in which people live) and receipt of psychotherapy among Veterans with posttraumatic stress disorder (PTSD) engaged in care at the Veterans Health Administration. Past research has identified disparities in receipt of PTSD care related to demographics, but there is a lack of research on disparities related to SDoH. This study investigated three SDoH: homelessness, socioeconomic disadvantage, and rurality. Using VHA electronic health records, we included Veterans with a PTSD diagnosis from 2015 to 2018, a total of 435,381 Veterans, and reviewed receipt of PTSD psychotherapy through 2019. In regression models accounting for demographics, trauma exposure, and mental and physical health factors, we found that Veterans who had experienced lifetime homelessness were more likely to receive any PTSD psychotherapy and a minimally adequate dose of PTSD psychotherapy (eight sessions within a 24-week period). We found that Veterans with greater socioeconomic disadvantage and Veterans who resided in rural areas were less likely to receive a minimally adequate dose of PTSD psychotherapy. These findings suggest that efforts are needed to promote engagement with mental healthcare for rural Veterans and those with greater socioeconomic disadvantage.

PURPOSE:Post-traumatic stress disorder (PTSD) is associated with poor health behaviors and risk for cardiovascular disease, and PTSD may impair cardiovascular disease recovery. Whether PTSD severity is a barrier to cardiac rehabilitation (CR) use following a new myocardial infarction (MI) or revascularization (percutaneous coronary intervention or coronary artery bypass grafting) is uncertain. METHODS:Eligible patients were identified from Veterans Health Administration historical medical record data. Patients (N = 5170) had 1 or more PTSD diagnoses and ≥1 PTSD Checklist score between October 1, 2011, and September 30, 2022. Modified Poisson models with robust error variance were computed before and after adjusting for covariates to measure the association between PTSD severity and any CR use in the 12 months after MI/revascularization. Among those who used CR, we determined if PTSD severity was linked to receiving 9 or more sessions. RESULTS:The sample was an average 62.1 ± 11.0 years of age, 95% male, and 77% identified as White race. During the 12-month follow-up period, 8% of the sample had any CR, and among those who did, 66% had ≥9 visits. The severity of PTSD was not significantly associated with any CR use nor with receipt of 9 or more encounters. CONCLUSIONS:Participation in CR was low regardless of PTSD severity. Although it is encouraging that higher PTSD severity is not a barrier to CR participation, increasing engagement of veterans in CR after MI/revascularization will be important for reducing their risk of recurrent events and mortality.

BACKGROUND:Co-use of cannabis and tobacco is increasing, but its impact on smoking cessation is not completely understood. It is unclear whether any cannabis use, or only problematic use such as cannabis use disorder (CUD), impacts smoking cessation. METHOD:In 2023, we conducted an online, national survey of US adults (n = 2,271) currently smoking cigarettes. We examined the association of past 30-day cannabis use (divided into three groups: co-use with CUD, co-use without CUD, and no cannabis use) with outcomes that can impact smoking cessation: self-rated importance, readiness, and confidence in quitting, barriers to cessation (Barriers to Cessation Scale, score range 0 to 57), and specific types of barriers (Addiction, Internal, and External barriers subscales). RESULTS:Interest in quitting smoking and self-rated importance was lowest in those with co-use without CUD, but self-rated readiness and confidence did not significantly differ among the three groups. Those with CUD reported the highest levels of barriers overall (total score of 20.3 for co-use with CUD, 15.2 for co-use use without CUD, and 16.4 for no cannabis use) and across all subscales. Adjusted subscale scores were higher for adults with CUD vs. cannabis use without CUD (Addiction: p = 0.03, External: p= 0<.001, Internal: <.001) and vs. no cannabis use (Addiction: p = 0.03, External: p = 0.02, Internal: p < 0.001). CONCLUSIONS:Adults who smoke cigarettes and use cannabis (vs. those smoking without cannabis co-use) report similar levels of readiness and confidence in quitting smoking. However, interest in and importance of quitting smoking was lowest in those reporting co-use without CUD and barriers were greatest in those reporting co-use with CUD. These populations may benefit from targeted interventions to address their unique challenges and improve smoking cessation.

This cohort study evaluates all-cause mortality of National Lung Screening Trial participants compared with those of similar age and tobacco use in a national Veterans Health Administration cohort.

Although the Veterans Health Administration (VHA) has strived to make posttraumatic stress disorder (PTSD) treatment widely available, the vast majority of veterans do not initiate evidence-based psychotherapy (EBP) for PTSD, which includes Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT). One prominent gap in the literature on PTSD EBP initiation is research on the role of social determinants of health (SDoH). In the current study, we used national survey and VHA data to investigate relationships between SDoH factors and PTSD EBP initiation. We used data collected in 2018 from a national, population-based, VHA-sponsored survey of post-9/11 veterans. We included VHA users with their first PTSD diagnosis in the electronic health record (EHR) from 2015 to 2018 (n = 678). Our outcome was PTSD EBP initiation, defined as at least one visit using a PE or CPT note template from 2015 to 2018 in the EHR. We conducted a logistic regression, with independent variables including demographic variables (age, gender, racial/ethnicity identity, sexual orientation, and marital status), time from PTSD diagnosis to end of 2018, service connection, trauma exposure (military sexual trauma [MST] and combat experience), and SDoH (education, homelessness, discrimination, legal involvement, socioeconomic disadvantage, and rurality). MST and greater time (from diagnosis to the end of the study) were associated with PTSD EBP initiation. Veterans reporting a history of having been to jail (legal involvement) were less likely to initiate a PTSD EBP. More research is needed to better understand why legal involved veterans are less likely to initiate a PTSD EBP.

Cannabis may cause chronic pulmonary disease. Prior studies have been limited by low cannabis exposure, lack of data on tobacco cigarettes, and/or limited numbers of those without tobacco cigarette use. To examine whether inhaled cannabis associated with asthma and chronic obstructive pulmonary disease, independent of tobacco cigarettes. Cross-sectional analysis of population-based, nationally representative survey data. Adults 18–74 years who participated in the 2016–2020 Behavioral Risk Factor Surveillance System surveys. The exposure was past-30-day cannabis use, from 0 (0/30 days) to 1 (30/30 days). Outcomes were self-reported diagnoses by a medical professional of asthma or chronic obstructive pulmonary disease. We used multivariable logistic regression to test whether inhaled cannabis was associated with odds of disease, adjusted for sociodemographics and tobacco cigarette use (current/former/never). Pre-specified analyses restricted to those with no lifetime tobacco cigarette use. Among n = 379,049, n = 23,035 reported inhaled cannabis use. Inhaled cannabis was associated with asthma overall (adjusted odds ratio (aOR) 1.44, 95

BACKGROUND:Little is known about the association between military sexual trauma (MST) and risk for suicide-related outcomes later in life. OBJECTIVE:To determine the association between MST and risk for suicide, overdose, and related mortality among older men and women at specific age landmarks and to investigate whether posttraumatic stress disorder (PTSD) modifies risk. DESIGN:Longitudinal cohort study; baseline in 2012 to 2013, with follow-up through 31 December 2020. SETTING:All U.S. Department of Veterans Affairs (VA) medical centers in the United States. PARTICIPANTS:5 059 526 veterans aged 50 years or older. MEASUREMENTS:Positive MST screening result, nonfatal suicide attempt, death by suicide, or overdose death. RESULTS:MST was documented for 15.7% of older women and 1.3% of older men. The adjusted cumulative incidence of any suicide attempt was higher for those with MST (men, 18.67%; women, 8.66%) than for those without MST (men, 6.25%; women, 2.92%) at age 90 years. The adjusted risk differences among men and women were 12.41% (95% CI, 11.72% to 13.10%) and 5.74% (CI, 5.22% to 6.26%) for any late-life suicide attempt, 11.92% (CI, 11.27% to 12.57%) and 5.58% (CI, 5.08% to 6.08%) for nonfatal suicide attempt, 0.27% (CI, 0.00% to 0.54%) and 0.15% (CI, 0.00% to 0.30%) for fatal suicide attempt, and 1.05% (CI, 0.79% to 1.31%) and 0.48% (CI, 0.28% to 0.68%) for any drug overdose at age 90 years. MST remained a significant risk factor for any suicide attempt among people with and without PTSD. LIMITATIONS:Selection bias, generalizability to non-VA veterans, possible unmeasured confounding, and missingness. CONCLUSION:Late-life suicide attempt and death by suicide or overdose are associated with prior MST. These findings advance our understanding of the lasting effect of sexual trauma on suicide risk and mortality and suggest that monitoring and treatment of MST-related conditions are vital over the long term. PRIMARY FUNDING SOURCE:VA Office of Research and Development.

BACKGROUND:Posttraumatic stress disorder (PTSD) is associated with risk for cardiovascular disease (CVD). Improved physical health often follows large decreases in PTSD severity, but it is not known if better CVD outcomes follow PTSD improvement in patients with comorbid PTSD and CVD. METHODS:De-identified medical record data between 2011 and 2022 was used to create a cohort of 7120 Veterans Health Administration patients with PTSD and comorbid CVD. The exposure was clinically meaningful PTSD improvement defined as ≥20-point PTSD Checklist (PCL) decrease. Entropy balance controlled for confounding. Cox proportional hazard models estimated the association between clinically meaningful PCL decrease and CVD outcomes: myocardial infarction or revascularization procedure, all-cause mortality, and stroke. RESULTS:About half (52.2 %) of the sample was 65-80 years of age, 95.5 % were male, 17.3 % identified as Black and 79.2 % as White race. Clinically meaningful PTSD improvement occurred for 20.4 % of patients. After controlling for confounding, those with vs. without clinically meaningful PTSD improvement did not significantly differ on risk for myocardial infarction or revascularization procedure (HR = 1.07; 95 %CI:0.94-1.20), all-cause mortality (HR = 1.02; 95 %CI:0.89-1.17), and stroke (HR = 1.10; 95 %CI:0.96-1.26). Neither race, age nor depression significantly modified the association of PTSD improvement and risk for adverse CVD outcomes. CONCLUSIONS:In this sample of veterans, large reductions in PTSD severity were not associated with better or worse CVD outcomes. Research is needed to determine if clinically meaningful PTSD improvement and the lack of association with CVD outcomes is seen in other populations of patients with comorbid PTSD and CVD.

Posttraumatic stress disorder (PTSD) has been linked with increased risk for hospitalization and death following COVID-19 infection, underscoring the importance of prevention in this population. Prior studies of pandemic-related behaviors in patients with PTSD have yielded mixed results. The present study used cross-sectional data from the Mind Your Heart Study to examine the association between PTSD and engagement in protective behaviors in a sample of 231 older Veterans assessed between July and October 2020 and to explore the role of perceived threat of COVID-19 in any observed associations. In adjusted analyses, probable PTSD was associated with greater engagement in protective behaviors (i.e. social distancing, disinfecting, protective equipment/medication, and health information behaviors), which was partially explained by greater perceived threat. PTSD may facilitate engagement in protective health behaviors, but some protective behaviors (i.e. social distancing) may have adverse implications for mental health.

BACKGROUND:Whether cannabis is a risk factor for cardiovascular events is unknown. We examined the association between smoking cannabis and cardiovascular events in a cohort of older veterans (66 to 68 years of age) with coronary artery disease. METHODS:The THC Cohort (Heart and Cannabis) comprised 4285 veterans (mean [SD] age, 67.5 [1.01] years; 2% female) with coronary artery disease who were born in 1950 to 1952. Participants were recruited between April 5, 2018, and March 12, 2020, interviewed about health behaviors, and then classified according to their self-reported cannabis smoking status in the previous 30 days. In a separate analysis, we classified participants according to any form of cannabis use (smoking, vaping, or edible use) versus nonuse in the past 30 days. Data on demographic, behavioral, and clinical characteristics were collected by telephone interview and from national Department of Veterans Affairs and Medicare data sources. The primary outcome included a composite of fatal and nonfatal stroke, fatal and nonfatal acute myocardial infarction, and cardiovascular death. The follow-up period for each patient extended from the date of their initial interview until the end of study (June 14, 2022). All participants were followed until they experienced an outcome or until the end of the follow-up period. Survey nonresponse weights and propensity score-based weights were used to reduce bias and confounding. Hazard ratios were estimated using cause-specific hazard models. RESULTS:The cohort included 1015 veterans with coronary artery disease who reported smoking cannabis in the previous 30 days and 3122 veterans who did not smoke cannabis in the previous 30 days. Mean follow-up was 3.3 years, and 563 events occurred. Compared with veterans who did not smoke cannabis, smoking cannabis (past 30 days) was not associated with the composite outcome of acute myocardial infarction, stroke, and cardiovascular death (adjusted hazard ratio, 0.87 [95% CI, 0.61-1.24]). Similarly, use of any form of cannabis (smoking, vaping, dabbing, edibles) in the past 30 days was not associated with the composite outcome. CONCLUSIONS:In this cohort of older veterans with coronary artery disease, self-reported cannabis use was not independently associated with increased cardiovascular events over a mean of 3.3 years of follow-up.

There are no reported randomized trials testing exercise versus an active comparator for Posttraumatic Stress Disorder (PTSD). This randomized clinical trial assessed the effectiveness of group exercise versus psychoeducation to improve quality of life and reduces symptomatic severity in Veterans with PTSD. Veterans who met criteria for current PTSD (DSM-5) and/or endorsed moderate levels of PTSD symptoms (CAPS 5 score ≥ 23) were randomly assigned to treatment. Integrative Exercise (IE) combines fitness exercises (aerobics, resistance training, stretching) with mindful body/breath awareness versus Recovery Class (REC) psychoeducation control condition. A total of 84 participants were enrolled of which 41 participants were randomized to IE and 43 participants to REC. There were no significant pre-post differences in change in the WHOQOL Psychological Domain in either group. There was a modest reduction in the total CAPS-5 score in both groups (IE: -8.2 (9.9), p < .001: REC: -7.8 (2.0), p < .001) but no differences across the two conditions. In the IE subsample that was remote, there was a greater improvement in PTSD symptom severity (F[1, 50] = 4.62, p = .036) and in in the WHOQOL Psychological Domain (F(1, 47) = 6.46, p = .014) in those who attended more sessions. Trial Registration: ClinicalTrials.gov Identifier: NCT02856412 (registration date: February 27, 2017)

The importance of psychological distress in patients with cardiovascular disease is increasingly recognized as both a contributing factor to the development and progression of cardiovascular disease and a consequence of the development of cardiovascular disease. Patients with acute myocardial infarction have increased risks for depression, anxiety, psychosocial stress, or posttraumatic stress disorder. Together, these negative psychological factors when occurring after myocardial infarction have been referred to as postmyocardial psychological distress. Up to half of patients after myocardial infarction may experience some form of psychological distress, and this postmyocardial psychological distress has been associated with an increased risk of future cardiac events. Biologically plausible mechanisms by which postmyocardial psychological distress may lead to increased future cardiac risk include lesser physical activity, smoking (and failure to stop smoking), excess alcohol consumption, poor diet, obesity, inadequate sleep, inadequate social support, decreased medication adherence, and poor attendance at cardiac rehabilitation. The data on whether treatment of postmyocardial psychological distress improves cardiac prognosis are mixed and of variable quality, and further studies, particularly in patients with anxiety, stress, and posttraumatic stress disorder, would be helpful. Regardless, multiple interventions can reduce psychological distress and thus lead to improved psychological health, a greater sense of emotional well-being, and a better quality of life. A goal of health care professionals should be to treat not only the disease but also the person as a whole in front of us.

Food insecurity is a well-established risk factor for disordered eating behaviors in non-veterans. Because United States (U.S.) veterans are vulnerable to both food insecurity and disordered eating, the present study aims to evaluate associations between food insecurity and binge eating, purging, dietary restraint/restriction, and night eating behaviors-commonly occurring disordered eating behaviors in U.S. veterans. A national sample of U.S. veterans completed an online survey (n = 405). General and generalized linear models evaluated associations between food insecurity (predictor variable) and disordered eating (outcome variables), adjusted for race, ethnicity, gender, age, education, and employment status. Compared with veterans with food security, food insecure veterans reported twice the number of binge eating episodes, almost four times the number of purging episodes, nearly a third more dietary restraint/restriction, and mildly-to-moderately worse night eating symptoms. Exploratory gender-stratified models suggested that the relationship between food insecurity and disordered eating behaviors, such as purging and night eating, may be stronger in veteran men than women. U.S. veterans with food insecurity demonstrate greater disordered eating, particularly night eating and purging behaviors, than those with food security. Gender differences suggest that disordered eating may function differently in men and women with food insecurity. The present study can inform screening and treatment of U.S. veterans with food insecurity and disordered eating, including the need to concurrently assess both issues. Given the cross-sectional design, future research is needed to clarify the temporal relationship between food insecurity and disordered eating in U.S. veterans and to elucidate similarities and differences by gender.

Importance:Little is known about patterns (forms, frequency, and reasons) and factors associated with cannabis use in older veterans (aged ≥65 years). Objective:To examine factors associated with past 30-day cannabis use and cannabis use disorder (CUD) in older veterans. Design, Setting, and Participants:In this cross-sectional study, community-dwelling adults aged 65 to 84 years who used Veterans Health Administration care were interviewed between February 5, 2020, and August 29, 2023. Exposure:Sociodemographic, behavioral, and health-related characteristics. Main Outcomes and Measures:Past 30-day cannabis use (smoking, vaping, dabbing, or edibles) and any CUD (≥2 criteria based on Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) were assessed using weighted multivariable logistic regressions. Results:Of the 4503 participants (weighted mean age, 73.3 years [95% CI, 73.0-73.5 years]; 85.4% [95% CI, 83.6%-87.2%] men), 58.2% (95% CI, 55.3%-61.0%) had ever used cannabis, 28.9% (95% CI, 26.0%-31.8%) of whom reported using cannabis for medical reasons, most commonly for pain (56.4%; 95% CI, 50.9%-61.9%), mood or mental health (18.4%; 95% CI, 14.7%-22.1%), and sleep (16.0%; 95% CI, 11.9%-20.0%). More than 1 in 10 reported past 30-day cannabis use (10.3%; 95% CI, 8.9%-11.7%), with 52.4% (95% CI, 45.4%-59.4%) of these using cannabis for 20 days or more; smoking (72.4%; 95% CI, 65.4%-79.3%) and edibles (36.9%; 95% CI, 29.8%-43.9%) were the most common forms of use. Characteristics associated with past 30-day use included younger age (65-75 years), economic hardship, tobacco and illicit drug use, and residing in a state with recreationally legal cannabis. Among those with past 30-day cannabis use, 36.3% (95% CI, 30.1%-42.6%) screened positive for CUD, with higher odds among younger respondents, those reporting anxiety, those with 1 or more deficits in activities of daily living, those with illicit drug use, those with frequent cannabis use, and those using cannabis recreationally. Past 30-day inhaled cannabis use, compared with edibles only, was associated with increased odds of any CUD (adjusted odds ratio, 3.56; 95% CI, 1.12-11.26). Conclusions and Relevance:In this cross-sectional study of cannabis use in older veterans, use was common, and more than one-third who used in the past 30 days had any CUD. The prevalence of past 30-day cannabis use was close to tobacco use prevalence, and risk factors for cannabis use were similar to those observed in other populations. Frequent and inhaled cannabis use was associated with higher odds of any CUD. Routine health screening for cannabis use in Veterans Health Administration clinical settings is necessary to identify older adults with cannabis use.

BACKGROUND:Little is known about whether cannabis legalization impacts cannabis use uptake or has spillover effects on co-use of cannabis and tobacco/nicotine (using both in the past 30 days). We determined associations of cannabis legalization with self-reported (1) current (past 30-day) cannabis use; (2) current ("now") tobacco/nicotine use (smoking or electronic cigarette use); and (3) current co-use of cannabis and tobacco/nicotine and how prevalence is changing over time. METHODS:In this longitudinal study, a web-based survey was administered to a nationally representative, population-based panel of US adults in 2017, 2020, and 2021. We used weighted unadjusted binomial logistic GEE models to assess changes in prevalence of cannabis, tobacco/nicotine use and co-use and weighted, adjusted binary logistic GEE models to assess associations of cannabis legalization with cannabis, tobacco/nicotine use and co-use. RESULTS:A total of 9003 participants (age range = 18-94, mean age = 47.9 [±17.4 SD] years; 4696 females [weighted 52.0 %]) completed the survey in 2017; 5979/8529 (70.1 %) in 2020 and 5420/7305 (74.2 %) in 2021 from the original cohort who remained available. Current cannabis use significantly increased +3.3 % between 2017 and 2021, while tobacco/nicotine use significantly declined (-1.9 %); co-use of cannabis and tobacco/nicotine did not change significantly (+0.2 %). Both medical and recreational cannabis legalization was associated with increased current cannabis use; the independent effect of recreational cannabis legalization was 1.13 times larger than medical. There were no statistically significant differences in tobacco/nicotine use and co-use prevalence by legalization status. CONCLUSION:Cannabis legalization increases cannabis use but is not associated with changes in tobacco/nicotine use or co-use. Legalization should be coupled with public health efforts.

Abstract Chronic pain is a major public health problem affecting approximately 100 million Americans and United States military Veterans, who constitute a particularly vulnerable group. While pain research in Veterans is actively underway, information on the longitudinal course of pain in this population is limited. This study aimed to 1) identify the various longitudinal pain status trajectories among older Veterans over a 10-year period and 2) detect factors predicting membership in the worsening trajectory of chronic pain. We analyzed data from 619 Veterans (mean age: 58.5 years) participating in the Mind Your Heart Study, an ongoing prospective cohort study examining diverse health outcomes among Veterans. Initially, we employed a generalized mixture model to identify pain trajectory classes using Brief Pain Inventory (BPI) pain intensity subscale score collected at 2-, 5-, and 10-year intervals. Two distinct trajectories were identified—low and high—both of which remained relatively stable. Subsequently, several feature selection methods extracted the predominant features from participants’ baseline characteristics that predicted membership in the high vs. low pain trajectory. These included: prior arthritis diagnosis; prior post-traumatic stress disorder (PTSD) diagnosis; depression symptoms; PTSD symptoms of avoidance, hyperarousal, and negative mood alterations; physical functioning; sleep quality; and overall health. The scikit-learn RandomForestClassifier, utilizing the refined feature set, achieved a classification accuracy of 0.79, yielding results nearly identical to those obtained using all 261 features. These findings are clinically informative and pertinent, highlighting potential intervention targets warranting intensive pain care plans based on probable long-term prognosis and discussing early treatment strategies among older Veterans.