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While major depression is known to be associated with glomerular filtration rate (GFR) decline, there is a lack of data on the association of other mental illnesses like posttraumatic stress disorder (PTSD) with kidney disease. In 640 adult participants of the Heart and Soul Study (mean baseline age of 66.2 years) with a high prevalence cardiovascular disease, hypertension and diabetes, we examined the association of PTSD with GFR decline over a 5 year follow-up. We observed a significantly greater estimated (e) GFR decline over time in those with PTSD compared to those without (2.97 versus 2.11 ml/min/1.73m

Posttraumatic stress disorder (PTSD) may be an important risk factor for cardiovascular disease (CVD). We explore the literature linking PTSD to CVD, potential mechanisms, interventions, and clinical implications. We outline gaps in current literature and highlight necessary future research.PTSD has been independently associated with deleterious effects on cardiovascular health through biological, behavioral, and societal pathways. There are evidence-based psychotherapeutic interventions and pharmacotherapies for PTSD that may mitigate its impact on CVD. However, there are limited studies that rigorously analyze the impact of treating PTSD on cardiovascular outcomes. Trauma-informed CVD risk stratification, education, and treatment offer opportunities to improve patient care. These approaches can include a brief validated screening tool for PTSD identification and treatment. Pragmatic trials are needed to test PTSD interventions among people with CVD and evaluate for improved outcomes.

Cannabis use may confer high COVID-19 risk. This study examined self-reported changes in cannabis use that US adults attributed to the pandemic and factors associated with any changes. We conducted a national, cross-sectional survey among US adults in August 2020. The analytic sample included 957 past-year cannabis users (M

Background Evidence on the cardiovascular health effects of cannabis use is limited. We designed a prospective cohort study of older Veterans (66 to 68 years) with coronary artery disease (CAD) to understand the cardiovascular consequences of cannabis use. We describe the cohort construction, baseline characteristics, and health behaviors that were associated with smoking cannabis. Objective To understand the cardiovascular consequences of cannabis use. Design We designed a prospective cohort study of older Veterans (66 to 68 years) with CAD. Participants A total of 1,015 current cannabis smokers and 3,270 non-cannabis smokers with CAD. Main Measures Using logistic regression, we examined the association of baseline variables with smoking cannabis in the past 30 days. Results The current cannabis smokers and non-current smokers were predominantly male (97.2% vs 97.1%, p=0.96). Characteristics associated with recent cannabis use in multivariable analyses included lack of a high school education (odds ratio [OR] 2.15, 95% confidence interval [CI]: 1.10 to 4.19), financial difficulty (OR 1.47, 95% CI: 1.02 to 2.11), tobacco use (OR 3.02, 95% CI: 1.66 to 5.48), current drug use (OR 2.82, 95% CI: 1.06 to 7.46), and prior drug use (OR 2.84, 95% CI: 2.11 to 3.82). In contrast, compared to individuals with 0 to 1 comorbid conditions, those with 5 chronic conditions or more (OR 0.43, 95% CI: 0.27 to 0.70) were less likely to smoke cannabis. Conclusions In this older high-risk cohort, smoking cannabis was associated with higher social and behavioral risk, but with fewer chronic health conditions.

ObjectiveHigh levels of psychological distress increase the risk of a wide range of medical diseases. In this study, we investigated the association between posttraumatic stress disorder (PTSD) and kidney disease.MethodsWorld Trade Center (WTC) responders were included if they had two or more measures of estimated glomerular filtration rate (eGFR). The PTSD Checklist (PCL) was used to define no PTSD (PCL < 40), "mild" PTSD (40 ≤ PCL

Background Mental health's impact on vascular surgical patients has long been overlooked. While outside the expertise of most surgeons, understanding the role that depression plays in the postoperative course could provide additional insight into opportunities to improve surgical outcomes and healthcare value. Additionally, non-home discharge (NHD) to a rehabilitation or skilled nursing facility after surgery is associated with impaired quality of life and higher postdischarge complications, readmissions, and mortality. We hypothesized that depression would be associated with an increased risk for NHD following abdominal aortic aneurysm (AAA) repair. Methods Nonruptured AAA repair cases were identified from the National Inpatient Sample (NIS) using ICD-9 codes between 2005 and 2014. Depression, comorbidities, postoperative complications, and discharge destination were evaluated using statistical tests as appropriate to the data. A hierarchical multivariable logistic regression controlling for hospital level variation was used to examine the independent association between depression, and the primary outcome of NHD controlling for median income and confounders meeting P Results There were 99,934 total cases analyzed, of which 4,755 (4.8%) were diagnosed with depression and 10,618 (11.9%) required NHD. Patients with depression were younger, more likely to be women, white, have diabetes, chronic obstructive pulmonary disease, hypertension, tobacco use, and more likely to experience a postoperative complication. On adjusted multivariable analysis, patients with depression were more likely to require NHD (odds ratio [OR] 1.87, 95% confidence interval [CI]: 1.68–2.08, c-statistic = 0.82). On stratified analysis by operative approach, depression had a larger effect estimate in endovascular repair (OR 2.19; 95% CI: 1.90–2.52) versus open repair (OR 1.60; 95% CI: 1.38–1.87). Conclusions In a nationally representative sample, patients with depression were more likely to require NHD after AAA repair. This study highlights the importance that depression plays in postoperative outcomes after AAA repair. Furthermore, addressing mental health preoperatively has the potential to improve outcomes in patients undergoing AAA repair.

This study examined whether expressive suppression (ES), a maladaptive regulation strategy, was more strongly associated with PTSD diagnosis and symptom clusters in veterans than cognitive reappraisal (CR), an adaptive regulation strategy.In a cohort study, 746 participants recruited from VHA facilities completed Clinician Administered PTSD Scale-IV, Emotion Regulation Questionnaire, and Patient Health Questionnaire. Participants were categorized into groups: Current, Remitted/Lifetime, and Never PTSD.One-way ANOVA revealed significant differences between Current PTSD and both Remitted and Never PTSD for ES, but not CR. The Remitted and Never PTSD groups did not vary significantly from each other and were collapsed into one group for regressions. Adjusting for sex, race, employment, and comorbid depression, binary logistic regression showed ES, but not CR, was associated with increased likelihood of Current PTSD (p.001, OR: 1.43). ES was also significantly associated with increased odds of meeting criteria for all symptom clusters (ps0.001). CR was not significantly associated with meeting criteria for Current PTSD or any symptom cluster.Cross-sectional design and use of self-report limit causality inferences that can be drawn.ES is associated with increased odds of Current PTSD diagnosis and symptom clusters. Veterans in the Remitted and Never PTSD groups did not differ significantly. Greater suppression of emotional expression is more strongly linked with PTSD criteria in veterans than decreased cognitive reappraisal.

Background and aims Opioid use and chronic pain are prevalent in the veteran population. Collaborative care enhances coordination between patients and their care teams, and motivational interviewing (MI) is a communication style designed to facilitate behavior change. This study evaluated the use of collaborative care with MI (CCMI) with patients with chronic pain and high-risk prescription opioid use. Design Small pilot study of a randomized controlled trial. Setting An urban Veterans Affairs (VA) Medical Center in the United States. Participants One hundred adult veterans with chronic pain currently enrolled into primary care and receiving long-term opioid therapy. Intervention and comparator During an initial 1-hour visit with a study primary-care physician (PCP), all veterans (n = 100) developed a personalized pain care plan, after which they were randomized to receive four sessions (at 4, 6, 8 and 12 weeks) of either CCMI (n = 51) or attention control psychoeducation (ACP; n = 49). Subsequently, participants had 30-minute follow-up visits with study PCPs and post-treatment assessment at 12 weeks. Measurements Co-primary outcomes measures assessed opioid risk and pain interference; secondary measures assessed pain severity, PCP rating of opioid risk and pain management goals. Findings At 12 weeks, intent-to-treat (ITT) analyses using multivariate mixed-effects linear regression were inconclusive regarding the between-group differences in primary and secondary outcomes at post-intervention (12 weeks). Bayes factors for opioid risk, pain interference, pain severity and PCP ratings were 1.96, 1.36, 0.45 and 0.82, respectively. Veterans in the CCMI group reported implementing more complementary integrative health (CIH) goals (e.g. yoga) than did those in the ACP group (d = 0.54). Conclusions US veterans with chronic pain who received collaborative care with motivational interviewing reduced their high-risk opioid use and showed improved pain interference and severity after an intake with a primary-care provider involving shared decision-making and the creation of a personalized pain care plan.

BackgroundPosttraumatic stress disorder (PTSD) is associated with increased risk for morbidity and mortality, which may be mediated through elevated inflammation. In contrast, social support appears to protect against morbidity and mortality, reduce levels of inflammation, and improve PTSD outcomes.MethodsWe examined relationships among social isolation, perceived social support, and inflammation in Veterans Affairs (VA) patients with and without PTSD. Our sample included 735 (35% PTSD+) participants from the Mind Your Heart Study (mean age=58±11; 94% male). Social isolation was assessed with the Berkman Syme Social Network Index; perceived social support with the Multidimensional Scale of Perceived Social Support; and PTSD with the Clinician Administered PTSD Scale. Inflammation was indexed by high sensitivity C-reactive protein, white blood cell count, and fibrinogen. Hierarchical linear regression was used to examine associations between social measures and inflammation. PROCESS was used to examine the interactive effects of social relationships and PTSD on inflammation.ResultsSocial isolation, but not low perceived social support, trended towards an association with elevated inflammation in the full sample. However, considering groups with and without PTSD separately, social isolation was significantly associated with all inflammatory markers among individuals without PTSD, but not among those with PTSD.ConclusionsSocial integration is associated with reduced inflammation in individuals without, but not with, PTSD. Socially integrated individuals with PTSD did not have lower levels of inflammatory markers than socially isolated individuals with PTSD.

Posttraumatic stress disorder (PTSD) is highly prevalent among veterans. Many veterans with PTSD respond well to serotonin reuptake inhibitors (SRIs). Nonresponders may be prescribed augmenting medications, which are not as well-studied in PTSD.We used Veterans Health Administration electronic records to compare mental health outcomes (PTSD symptoms and rates of mental health hospitalizations and psychiatric emergency room visits) in patients with PTSD who were prescribed four different groups of augmenting medications (atypical antipsychotics, mirtazapine, prazosin or tricyclic antidepressants) in addition to SRIs-from the year before to the year after the start of the augmenting medication.We included data from 169,982 patients with a diagnosis of PTSD (excluding patients with comorbid bipolar or psychotic disorders) seen in Veterans Affairs care from 2007 to 2015 who were taking an SRI and filled a new prescription for one of the four augmenting medications for at least 60 days.Patients evidenced minimal (2%) reduction in PTSD symptoms and a larger reduction in psychiatric hospitalizations and psychiatric emergency room visits after receiving augmenting medications; this effect was largely similar across the four medication groups. Initiating augmenting medications was preceded by increases in PTSD symptoms, psychiatric hospitalizations and psychiatric emergency room visits. After initiating an augmenting medication, PTSD symptoms/hospitalizations/emergency room visits returned to baseline levels (before the start of the augmenting medication), but generally did not improve beyond baseline.Importantly, these effects could be explained by regression to the mean, additional interventions or confounding. These findings should be further explored with placebo controlled randomized clinical trials.

OBJECTIVE: Exposure to stressors in daily life and dysregulated stress responses are associated with increased risk for a variety of chronic mental and physical health problems, including anxiety disorders, depression, asthma, heart disease, certain cancers, and autoimmune and neurodegenerative disorders. Despite this fact, stress exposure and responses are rarely assessed in the primary care setting and infrequently targeted for disease prevention or treatment. METHOD: In this narrative review, we describe the primary reasons for this striking disjoint between the centrality of stress for promoting disease and how rarely it is assessed by summarizing the main conceptual, measurement, practical, and reimbursement issues that have made stress difficult to routinely measure in primary care. The following issues will be reviewed: (1) assessment of stress in primary care; (2) biobehavioral pathways linking stress and illness; (3) the value of stress measurements for improving outcomes in primary care; (4) barriers to measuring and managing stress; and (5) key research questions relevant to stress assessment and intervention in primary care. RESULTS: Based on our synthesis, we suggest several approaches that can be pursued to advance this work, including feasibility and acceptability studies, cost-benefit studies, and clinical improvement studies. CONCLUSIONS: Although stress is recognized as a key contributor to chronic disease risk and mortality, additional research is needed to determine how and when instruments for assessing life stress might be useful in the primary care setting, and how stress-related data could be integrated into disease prevention and treatment strategies to reduce chronic disease burden and improve human health and wellbeing.

Introduction Improvement in posttraumatic stress disorder (PTSD) is associated with better health behavior such as better medication adherence and greater use of nutrition and weight loss programs. However, it is not known if reducing PTSD severity is associated with smoking cessation, a poor health behavior common in patients with PTSD. Aims and Methods Veterans Health Affairs (VHA) medical record data (2008–2015) were used to identify patients with PTSD diagnosed in specialty care. Clinically meaningful PTSD improvement was defined as ≥20 point PTSD Checklist (PCL) decrease from the first PCL ≥50 and the last available PCL within 12 months and at least 8 weeks later. The association between clinically meaningful PTSD improvement and smoking cessation within 2 years after baseline among 449 smokers was estimated in Cox proportional hazard models. Entropy balancing controlled for confounding. Results On average, patients were 39.4 (SD = 12.9) years of age, 86.6% were male and 71.5% were white. We observed clinically meaningful PTSD improvement in 19.8% of participants. Overall, 19.4% quit smoking in year 1 and 16.6% in year 2. More patients with versus without clinically meaningful PTSD improvement stopped smoking (n = 36, cumulative incidence = 40.5% vs. 111, cumulative incidence = 30.8%, respectively). After controlling for confounding, patients with versus without clinically meaningful PTSD improvement were more likely to stop smoking within 2 years (hazard ratio = 1.57; 95% confidence interval: 1.04–2.36). Conclusions Patients with clinically meaningful PTSD improvement were significantly more likely to stop smoking. Further research should determine if targeted interventions are needed or whether improvement in PTSD symptoms is sufficient to enable smoking cessation. Implications Patients with PTSD are more likely to develop chronic health conditions such as heart disease and diabetes. Poor health behaviors, including smoking, partly explain the risk for chronic disease in this patient population. Our results demonstrate that clinically meaningful PTSD improvement is followed by greater likelihood of smoking cessation. Thus, PTSD treatment may enable healthier behaviors and reduce risk for smoking-related disease.

Background Despite programs to address housing for Veterans, they continue to be at high risk of unstable housing. Interpersonal violence is also highly prevalent among Veterans and may contribute to unstable housing. Our study aimed to determine whether interpersonal violence was associated with unstable housing among Veterans, and how this association was influenced by common co-occurring conditions such as substance use and mental illness. Methods Veterans in the Mind Your Heart Study (N = 741) completed survey data on history of interpersonal violence and access to housing in the prior year. Interpersonal violence was defined as experiencing sexual violence, physical violence, or mugging/physical attack using the Brief Trauma Questionnaire. Multivariable models examined associations between interpersonal violence and unstable housing. Primary models were adjusted for age and sex. Potential explanatory factors were added in subsequent models, including marital status, education, income, substance use disorder, PTSD, and other mental illness. Results Veterans who had experienced interpersonal violence had almost twice the odds of unstable housing after adjustment for age and sex (AOR 1.9, 95% CI 1.2–3.0). This association was attenuated in the fully adjusted model including substance use, PTSD, and other mental illness, illustrating the interdependence of these factors (AOR 1.5, 95% CI 0.91–2.5). Subtypes of interpersonal violence were individually associated with increased odds of unstable housing after adjustment for age and sex (physical abuse AOR 1.7, 95% CI 1.2–2.5; mugging/physical attack AOR 1.8, 95% CI 1.2–2.7; sexual violence AOR 1.4, 95% CI 0.89–2.2), but were no longer significant in the fully adjusted model. Conclusions Previous experiences of interpersonal violence were associated with unstable housing among Veterans. Substance use, PTSD, and other mental illness played an important role in this relationship—highlighting the potential to improve health outcomes through trauma informed approaches that address mental health, substance use, and housing concurrently.

IntroductionApproximately half of individuals with posttraumatic stress disorder (PTSD) may meet criteria for other psychiatric disorders, and PTSD symptoms are associated with diminished health and psychosocial functioning. However, few studies examine the longitudinal progression of PTSD symptoms concurrent with related symptom domains and functional outcomes, such that may neglect important longitudinal patterns of symptom progression beyond PTSD specifically.MethodsTherefore, we used longitudinal causal discovery analysis to examine the longitudinal interrelations among PTSD symptoms, depressive symptoms, substance abuse, and various other domains of functioning in five longitudinal cohorts representing veterans (n = 241), civilians seeking treatment for anxiety disorders (n = 79), civilian women seeking treatment for post-traumatic stress and substance abuse (n = 116), active duty military members assessed 0–90 days following TBI (n = 243), and civilians with a history of TBI (n = 43).ResultsThe analyses revealed consistent, directed associations from PTSD symptoms to depressive symptoms, independent longitudinal trajectories of substance use problems, and cascading indirect relations from PTSD symptoms to social functioning through depression as well as direct relations from PTSD symptoms to TBI outcomes.DiscussionOur findings suggest PTSD symptoms primarily drive depressive symptoms over time, tend to show independence from substance use symptoms, and may cascade into impairment in other domains. The results have implications for refining conceptualization of PTSD co-morbidity and can inform prognostic and treatment hypotheses about individuals experiencing PTSD symptoms along with co-occurring distress or impairment.

Supplemental Digital Content is available in the text, Objective: Beliefs about marijuana use and prevalence of use may be associated with the legalization status of the state of residence. We examined differences in views and rates of use of marijuana among residents in recreationally legal, medically legal, and nonlegal states. Methods: We surveyed a nationally representative online panel of US adults (N = 16,280) and stratified results by marijuana legalization status of states. We compared views of residents of recreational states on benefits and risks of marijuana use to residents in other states. Results: The response rate was 56.3% (n = 9003). Residents in recreationally legal states were more likely to believe marijuana could be beneficial for pain management (73% in recreationally legal states, 67% in medically legal states, 63% in nonlegal states; P value

There is a growing body of evidence that peripheral artery disease (PAD) may be impacted by depression. The objective of this study is to determine whether outcomes, primarily major amputation, differ between patients with depression and those without who presented to hospitals with critical limb ischemia (CLI), the end-stage of PAD. A retrospective cohort of patients hospitalized for CLI during 2012 and 2013 was identified from the National Inpatient Sample (NIS) using ICD-9 codes. The primary outcome was major amputation and secondary outcomes were length of stay and other complications. The sample included 116,008 patients hospitalized for CLI, of whom 10,512 (9.1%) had comorbid depression. Patients with depression were younger (64 ± 14 vs 67 ± 14 years, p < 0.001) and more likely to be female (55% vs 41%, p < 0.001), white (73% vs 66%, p < 0.001), and tobacco users (46% vs 41%, p < 0.001). They were also more likely to have prior amputations (9.8% vs 7.9%, p < 0.001). During the hospitalization, the rate of major amputation was higher in patients with comorbid depression (11.5% vs 9.1%, p < 0.001). In multivariable analysis, excluding patients who died prior to/without receiving an amputation ( n = 2621), comorbid depression was associated with a 39% increased odds of major amputation (adjusted OR 1.39, 95% CI 1.30, 1.49; p < 0.001). Across the entire sample, comorbid depression was also independently associated with a slightly longer length of stay (β = 0.199, 95% CI 0.155, 0.244; p < 0.001). These results provide further evidence that depression is a variable of interest in PAD and surgical quality databases should include mental health variables to enable further study.

BACKGROUND Those with posttraumatic stress disorder (PTSD) have lower overall functioning than healthy controls. However, this population is not homogenous, and those with PTSD have a wide range of functional outcomes. To our knowledge, only one other study has evaluated the predictors of better functioning within patients with PTSD. METHODS We examined 254 veterans with likely PTSD, using the Clinician-Administered PTSD Scale to assess PTSD symptom severity, and the SF-36 and single-item question to assess aspects of current functioning and quality of life. RESULTS In fully adjusted models (controlling for age, gender, and PTSD score, and including all significant psychosocial predictors of the outcome of interest), greater sleep quality (p = .03), lower C-reactive protein (p

Posttraumatic stress disorder (PTSD) is characterized by a persistent maladaptive reaction after exposure to severe psychological trauma. Traumatic events that may precipitate PTSD include violent personal assaults, natural and human-made disasters, and exposure to military combat or warfare. There is a growing body of evidence for associations of PTSD with major risk factors for cardiovascular disease (CVD), such as hypertension and diabetes, as well as with major CVD outcomes, such as myocardial infarction and heart failure. However, it is unclear whether these associations are causal or confounded. Furthermore, the biological and behavioral mechanisms underlying these associations are poorly understood. Here, the available evidence on the association of PTSD with CVD from population, basic, and genomic research as well as from clinical and translational research are reviewed, seeking to identify major research gaps, barriers, and opportunities in knowledge acquisition and technology as well as research tools to support and accelerate critical research for near-term and longer-term translational research directions. Large-scale, well-designed prospective studies, capturing diverse and high-risk populations, are warranted that include uniform phenotyping of PTSD as well as broad assessment of biological and behavioral risk factors and CVD outcomes. Available evidence from functional brain imaging studies demonstrates that PTSD pathophysiology includes changes in specific anatomical brain regions and circuits, and studies of immune system function in individuals with PTSD suggest its association with enhanced immune inflammatory activity. However, establishment of animal models and human tissue biobanks is also warranted to elucidate the potential causal connection of PTSD-induced brain changes and/or inflammation with CVD pathophysiology. Emerging large-scale genome-wide association studies of PTSD will provide an opportunity to conduct mendelian randomization studies that test hypotheses regarding the presence, magnitude, and direction of causal associations between PTSD and CVD outcomes. By identifying research gaps in epidemiology and genomics, animal, and human translational research, opportunities to better justify and design future interventional trials are highlighted that may test whether treatment of PTSD or underlying neurobiological or immune dysregulation may improve or prevent CVD risk or outcomes.

Objective To evaluate longitudinal prescription practice trends for patients diagnosed with posttraumatic stress disorder (PTSD) using a national cohort of veterans who engaged in Veterans Health Administration (VHA) care from 2009 to 2018. Methods Using ICD-9 and ICD-10 codes to determine diagnoses, 1,353,416 patients diagnosed with PTSD in VHA care were retrospectively identified who were not diagnosed with bipolar or psychotic spectrum disorder. Veterans were included in the analytic sample starting in the year of their first PTSD diagnosis for each year that they were active in VHA care. Outpatient prescription records were examined from 2009 to 2018 for medications that are commonly used as recommended (selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors [SNRIs]) or second-line/adjunctive (atypical antipsychotics [AAPs], mirtazapine, prazosin, trazodone, tricyclic antidepressants, and non-benzodiazepine hypnotics) medications for PTSD. Benzodiazepine prescriptions were also examined. Results From 2009 to 2018, the percentage of patients active in VHA care who received at least one of the examined recommended or second-line/adjunctive medications for PTSD in a calendar year declined by 9.0% (absolute change). The largest absolute change in rates of prescribing for medication classes over the last decade were observed among SSRIs (-12.3%) and SNRIs (+6.4%). AAP use decreased 5.4% from 2009 to 2018, with most of this change (-4.3%) occurring from 2009 to 2013. Conclusions Consistent with clinical practice guidelines, SSRIs/SNRIs were the most common prescriptions for patients in the current study. Reductions in the percentage of patients receiving PTSD medications may reflect concerns regarding effectiveness, adverse side effects, increases in access to evidence-based psychotherapy for PTSD, and/or symptom improvement such that medication was no longer needed.

IMPORTANCE: Posttraumatic stress disorder (PTSD) is associated with greater risk of ischemic heart disease (IHD) in predominantly male populations or limited community samples. Women veterans represent a growing, yet understudied, population with high levels of trauma exposure and unique cardiovascular risks, but research on PTSD and IHD in this group is lacking. OBJECTIVE: To determine whether PTSD is associated with incident IHD in women veterans. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective, longitudinal cohort study of the national Veterans Health Administration (VHA) electronic medical records, the a priori hypothesis that PTSD would be associated with greater risk of IHD onset was tested. Women veterans 18 years or older with and without PTSD who were patients in the VHA from January 1, 2000, to December 31, 2017, were assessed for study eligibility. Exclusion criteria consisted of no VHA clinical encounters after the index visit, IHD diagnosis at or before the index visit, and IHD diagnosis within 90 days of the index visit. Propensity score matching on age at index visit, number of prior visits, and presence of traditional and female-specific cardiovascular risk factors and mental and physical health conditions was conducted to identify women veterans ever diagnosed with PTSD, who were matched in a 1:2 ratio to those never diagnosed with PTSD. Data were analyzed from October 1, 2018, to October 30, 2020. EXPOSURES: PTSD, defined by International Classification of Diseases, Ninth Revision (ICD-9), or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), diagnosis codes from inpatient or outpatient encounters. MAIN OUTCOMES AND MEASURES: Incident IHD, defined as new-onset coronary artery disease, angina, or myocardial infarction, based on ICD-9 and ICD-10 diagnosis codes from inpatient or outpatient encounters, and/or coronary interventions based on Current Procedural Terminology codes. RESULTS: A total of 398 769 women veterans, 132 923 with PTSD and 265 846 never diagnosed with PTSD, were included in the analysis. Baseline mean (SD) age was 40.1 (12.2) years. During median follow-up of 4.9 (interquartile range, 2.1-9.2) years, 4381 women with PTSD (3.3%) and 5559 control individuals (2.1%) developed incident IHD. In a Cox proportional hazards model, PTSD was significantly associated with greater risk of developing IHD (hazard ratio [HR], 1.44; 95% CI, 1.38-1.50). Secondary stratified analyses indicated that younger age identified women veterans with PTSD who were at greater risk of incident IHD. Effect sizes were largest for those younger than 40 years at baseline (HR, 1.72; 95% CI, 1.55-1.93) and decreased monotonically with increasing age (HR for ≥60 years, 1.24; 95% CI, 1.12-1.38). CONCLUSIONS AND RELEVANCE: This cohort study found that PTSD was associated with increased risk of IHD in women veterans and may have implications for IHD risk assessment in vulnerable individuals.

As clinicians delivering health care, we are very good at treating disease but often not as good at treating the person. The focus of our attention has been on the specific physical condition rather than the patient as a whole. Less attention has been given to psychological health and how that can contribute to physical health and disease. However, there is now an increasing appreciation of how psychological health can contribute not only in a negative way to cardiovascular disease (CVD) but also in a positive way to better cardiovascular health and reduced cardiovascular risk. This American Heart Association scientific statement was commissioned to evaluate, synthesize, and summarize for the health care community knowledge to date on the relationship between psychological health and cardiovascular health and disease and to suggest simple steps to screen for, and ultimately improve, the psychological health of patients with and at risk for CVD. Based on current study data, the following statements can be made: There are good data showing clear associations between psychological health and CVD and risk; there is increasing evidence that psychological health may be causally linked to biological processes and behaviors that contribute to and cause CVD; the preponderance of data suggest that interventions to improve psychological health can have a beneficial impact on cardiovascular health; simple screening measures can be used by health care providers for patients with or at risk for CVD to assess psychological health status; and consideration of psychological health is advisable in the evaluation and management of patients with or at risk for CVD.

Electronic Health Records (EHRs) are typically stored as time-stamped encounter records. Judicious interpretation of temporal relationship between medical records is an integral part of assessing clinical information. Analogously, data analyzed by statistical or data mining methods need to contain time-interdependent analysis variables (TIAVs), whose values represent the clinical embodiment to be investigated. Unlike directly measured data, TIAV formulation is an iterative collaboration between programmer and investigator. This is because clinical TIAVs are context specific and often not absolute, and a custom program is needed to create and assess TIAVs. With rapidly growing interest in mining EHRs, there is a need for scalable solutions to optimize TIAV generation. We describe a framework of using sequences of time-referenced entities as building blocks. Scripts of simple functions are used with these entities to create TIAVs that incorporates multiple interdependencies, hence reducing the need for custom programs. We provide three examples to illustrate the principles of this method using the Veterans Health Administration’s EHR data.

Introduction: Implantable cardioverter defibrillators (ICD) reduce the risk of sudden cardiac death among patients with persistently low (≤35%) left ventricular ejection fraction (LVEF) at least 40 days following acute myocardial infarction (AMI). There are limited data about clinical factors associated with ICD placement following AMI. Hypothesis: We hypothesized that increasing age and number of comorbidities would decrease the odds of ICD placement post-AMI among patients with low (≤35%) LVEF, while revascularization for AMI would increase odds of ICD use. Methods: We used ICD-9 and 10 codes to identify all Veterans hospitalized for AMI from 2004-2017 and excluded Veterans with prior ICD and those who died during AMI hospitalization. We used a validated natural language processing algorithm to determine LVEF from echocardiograms performed 40-365 days post-AMI and identified patients with LVEF ≤35%. Using multivariable logistic regression, we examined the association of demographics, comorbidities, revascularization status for AMI, and prescription of guideline-directed medical therapy (GDMT) with the primary outcome of ICD placement 41-365 days post-AMI. Results: Of 10,447 Veterans eligible for an ICD, 1,966 (18.8%) received an ICD. Of 1,966 patients who received an ICD 7.1% died within 1-year, compared with 26.8% of patients who did not receive an ICD. In multivariable analysis, younger age, fewer comorbidities, revascularization during AMI hospitalization, and use of GDMT were associated with increased odds of receiving an ICD (Table). Eligible Black patients were less likely (OR 0.78, 95% CI 0.67-0.90) to receive an ICD than White patients. Conclusions: Many factors affect ICD placement among patients with reduced LVEF post-AMI. In particular, Black patients were less likely to receive ICDs than White patients. Future qualitative work could provide a deeper understanding of how patient and clinician factors influence decisions around ICD use.

BackgroundApproximately half of patients with posttraumatic stress disorder (PTSD) also meet criteria for internalizing disorders, yet few studies assess reciprocal longitudinal relations among these symptoms.MethodsWe used longitudinal causal discovery in a veteran cohort for hypothesis-generation about PTSD and internalizing symptom drivers (n=240), followed by hypothesis-testing in two independent civilian cohorts with similar symptom assessments over time (n=79 and n=116).ResultsIn the veteran cohort, causal discovery revealed PTSD symptoms drove internalizing symptoms, which subsequently impacted social functioning; all independent of problematic alcohol use. This replicated in treatment-seeking anxiety disorders (AD, n = 79) and substance abuse (SA, n = 116) samples with significantly better model fit for PTSD symptoms driving internalizing symptoms, versus internalizing symptoms driving PTSD symptoms (BIC change for AD sample = 175.1, pConclusionsOur findings suggest that internalizing symptoms that emerge in the context of PTSD are more likely to be driven by PTSD symptoms. These results highlight the need for a PTSD- and trauma-informed approach to treating internalizing symptoms, and provide preliminary evidence for cognition and mood disruption as a factor driving comorbidity.

BackgroundVeterans are disproportionately affected by symptoms of post-traumatic stress (PTS) and associated poor health and psychosocial functioning. While most improve over time, others experience severe and persistent concerns. The ability to predict this latter group is critical for early intervention. Characterizing this subgroup has proven difficult, with most studies focusing on PTS and neglect a wider assessment of veterans’ wellbeing. Consequently, little is known about veterans who experience chronic symptoms and far-reaching impairment.MethodThe present study uses dimension reduction, growth mixture modeling, and clustering methods to identify veterans with the worst-faring trajectories of psychiatric symptoms, health, and psychosocial functioning, using data from the seven-year Mind Your Heart study (MYH) of people receiving Veterans Affairs services (n = 747). Random forest classification and feature selection were then used to examine predictors that distinguish the worst-fairing veteran group from others in the cohort.ResultsThe combined analyses revealed a subgroup of veterans with severe and diverse symptoms across psychiatric domains, impairment in multiple facets of living, and poor health with deterioration over seven years. This subgroup was distinguished by transdiagnostic symptom severity and greater social isolation, avoidance, anhedonia, cynicism, anger/hostility, and immune response and inflammation.ConclusionsVeterans whose distress spans multiple domains appear to be more broadly impaired, socially isolated, cynical or angry/hostile to others, and show elevated immunoreactivity and inflammation. Care for this population should be informed by a multidisciplinary approach that is conscious of veterans’ mental and physical health, and interpersonal needs.

Substantial research has investigated the impact of social support on the development and course of suicidal thoughts and behaviors. However, its measurement has been inconsistent, and different facets of social support may have differential effects on suicidal ideation (SI). The present study used data from 743 veterans recruited between 2008 and 2010 as part of the Mind Your Heart Study to investigate the relationship between two aspects of social support (social network size and perceived social support) and SI over 9 years. Using the 9th item of the PHQ-9, we created two composite scores: (1, chronicity) the proportion of years the participant endorsed SI and (2, severity) the severity of SI across the follow-up period. We found that, when modeled individually, both larger social network size and greater perceived social support predicted lower SI chronicity (β=-.16, β = -0.19 respectively; ps .001) and lower SI severity (β=-0.15 and β = -0.19, respectively; ps .001). However, when modeled together and controlling for PTSD and depression symptoms, increased social network size but not perceived social support predicted lower SI chronicity (β=-0.09, p = .01 and β = 0.02, p = .48, respectively) and SI severity (β=-0.07, p = .045 and β = 0.01, p = .71, respectively). These findings suggest that social network size may be an important target for intervention, and that future work is needed to better delineate the effect of different features of social support on risk for suicide.

BACKGROUND: Due to concerns of inadequate primary care access, national agencies like the Health Resources and Services Administration (HRSA) support primary care (PC) residencies. Recent research demonstrates that up to 35% of PC alumni lost interest in PC during residency. These alumni who lost interest noted that their continuity clinic experience influenced their career choice. The purpose of this study was to identify the specific aspects of PC residency experience that influenced career choice. METHODS: We conducted a cross-sectional electronic survey of a PC internal medicine alumni cohort (2000–2015) from a large, academic residency. Our primary predictor was PC career and our primary outcome was influential factors on career choice. We performed chi-squared or Fisher’s exact tests for categorical variables and t tests for continuous variables. RESULTS: Of the 317 PC alumni in the last 15 years, 305 were contacted. One hundred seventy-two (56%) responded with 94 (55%) reporting current careers in PC and 78 (45%) in non-PC fields. Ninety-four percent of respondents expressed interest prior to residency, while only 68% remained interested at the conclusion of residency. Sixty-one percent of PC alumni rated the overall clinic experience as the most influential factor towards their ultimate career choice. The patient-physician relationship was the most frequently endorsed positively influential factor in career choice in both groups (95% of PC alumni, 76% non-PC). There was no difference among all alumni in common frustrations of clinic including clerical duties, encounter documentation, or visit length. Similarly, resident debt did not differ between groups. CONCLUSIONS: Strong interpersonal relationships with patients and clinic mentors were associated with a PC career. These factors may compensate for the reported frustrations of clinic. Enhancing patient and mentor relationships may increase the retention of PC residents in ambulatory careers and may help address the current and projected shortage of primary care physicians. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-06625-8.

Population-based data suggest that individuals who consume large dietary amounts of n-3 polyunsaturated fatty acids (PUFA) have lower odds of peripheral artery disease (PAD); however, clinical studies examining n-3 PUFA levels in patients with PAD are sparse. The objective of this study is to compare erythrocyte membrane fatty acid (FA) content between patients with PAD and controls. We conducted a cross-sectional study of 179 vascular surgery outpatients (controls, 34; PAD, 145). A blood sample was drawn and the erythrocyte FA content was assayed using capillary gas chromatography. We calculated the ratio of the n-3 PUFA eicosapentaenoic acid (EPA) to the n-6 PUFA arachidonic acid (ARA) as well as the omega-3 index (O3I), a measure of erythrocyte content of the n-3 PUFA, EPA, and docosahexaenoic acid (DHA), expressed as a percentage of total erythrocyte FA. Compared with controls, patients with PAD smoked more and were more likely to have hypertension and hyperlipidemia (p

OBJECTIVE Posttraumatic stress disorder (PTSD) is associated with increased risk for cardiometabolic disease. Clinically meaningful PTSD improvement is associated with a lower risk for diabetes, but it is not known if similar associations exist for incident hypertension, hyperlipidemia, and clinically relevant weight loss (i.e., ≥5% loss). METHOD Medical record data from Veterans Health Affairs patients with clinic encounters between fiscal year (FY) 2008 to 2015 were used to identify patients with worsening or no PTSD improvement (i.e., PTSD checklist (PCL) score decrease

BACKGROUND: The use of marijuana for medical purposes is increasing in parallel with expanding legalization and decreased public perception of harm. Despite this increase in use, it is unclear which medical conditions patients are attempting to treat with marijuana and whether they are communicating with medical providers about their use. OBJECTIVE: To understand the medical reasons for marijuana use, forms of marijuana used for medical purposes, and disclosure of use to physicians. DESIGN: National, probability-based online survey. SETTING: The USA, 2017. PARTICIPANTS: 16,280 US adults. MAIN MEASURE: Proportion of US adults who agreed with a statement. KEY RESULTS: A total of 9003 participants completed the survey (55% response rate). Five hundred ninety-one (7% of US adults) reported using marijuana for medical purposes. The most common medical reasons for marijuana use were anxiety (49%), insomnia (47%), chronic pain (42%), and depression (39%). The most common forms of use for all medical conditions were smoking and edibles, followed by vaping, concentrate, and topical. We found women were more likely to use marijuana for posttraumatic stress disorder, sleep, anxiety, and migraines. We did not find substantial variation in medical reasons for marijuana use by race. Among those using marijuana for medical purposes, 21% did not have a doctor. Among those with doctors, 33% did not inform them, 28% reported their doctor was neutral on their use, 32% reported their doctor was supportive, and 8% reported their doctor was not supportive. Those who lived in states where medical marijuana was illegal were less likely to disclose use to their doctor. LIMITATION: The online format of the survey may have caused selection bias. Wording of the questions may have affected interpretation. Doctors were not queried directly, rather participants were asked about their perception of doctor attitudes. CONCLUSION: Americans are using marijuana to treat medical conditions despite lack of evidence of efficacy. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05800-7) contains supplementary material, which is available to authorized users.

To further define the age-related distribution of diastolic function as defined by E/A ratio, in healthy male adults. The age-sensitive ratio of mitral inflow E-wave to A-wave (E/A) velocity is often considered in the evaluation of diastolic function. To appropriately direct a comprehensive evaluation of diastolic function, we sought to improve the characterization of the influence of age on E/A ratio. We analyzed echocardiographic data from the Mind Your heart Study, a cohort of outpatients recruited from two San Francisco Veterans centers to examine the effect of mental health on cardiovascular outcomes. Individuals with a history of heart disease or hypertension were excluded, leaving 313 veterans for analysis. We examined E/A by 5-year increments and performed linear and logistic regression analysis to predict trends in E/A and E dominance. Within the age ranges of population (54.9 ± 11.5), there is a steady gradual decline in absolute E/A ratio (beta coefficient/year- 0.018, P < .001) and the odds of E dominance similarly declines with age (odds ratio/year = 0.89, P < .001). Despite this decline, 90% of individuals below the age of 50 years maintain E dominance. Beyond age 50, 55% maintain E dominance, and beyond age 70, only 28% have E dominance. In this adequately healthy population, age-related progression of delayed relaxation appears to be a state of normality rather than diastolic dysfunction. Careful attention to specific cutoff points in age and E/A ratio could avoid misinterpretation or inappropriate management.

Background Posttraumatic stress disorder (PTSD) is prevalent among military veterans and is associated with significant negative health outcomes. However, stigma and other barriers to care prevent many veterans from pursuing traditional mental health treatment. We developed a group-based Integrative Exercise (IE) program combining aerobic and resistance exercise, which is familiar to veterans, with mindfulness-based practices suited to veterans with PTSD. This study aimed to evaluate the effects of IE on PTSD symptom severity and quality of life, as well as assess the feasibility and acceptability of IE. Methods Veterans (N = 47) were randomized to either IE or waitlist control (WL). Veterans in IE were asked to attend three 1-h group exercise sessions for 12 weeks. Results Compared with WL, veterans randomized to IE demonstrated a greater reduction in PTSD symptom severity (d = −.90), a greater improvement in psychological quality of life (d = .53) and a smaller relative improvement in physical quality of life (d = .30) Veterans’ ratings of IE indicated high feasibility and acceptability. Limitations The sample was relatively small and recruited from one site. The comparison condition was an inactive control. Conclusions This initial study suggests that IE is an innovative approach to treating veterans with symptoms of PTSD that reduces symptoms of posttraumatic stress and improves psychological quality of life. This approach to recovery may expand the reach of PTSD treatment into non-traditional settings and to veterans who may prefer a familiar activity, such as exercise, over medication or psychotherapy.

It is not clear from prior studies whether trauma exposure predicts substance use problems independent of psychiatric comorbidities. Most prior studies were cross-sectional in nature, and none focused on prescription drug problems. To address this gap in the literature, the current article is a secondary analysis of veterans from the Mind Your Heart prospective cohort study. The primary research question is whether trauma exposure predicts prescription drug problems even after controlling for major psychiatric symptoms, such as post-traumatic stress disorder and depression. Multinomial logistic regression was used to assess whether the 10-item lifetime Brief Trauma Questionnaire (e.g., serious car accidents, war traumas, life-threatening illness, natural disasters, physical, or sexual abuse) predicts prescription drug problems as determined by a self-report categorical question (three answer choices) over a 4-year follow-up time period (n = 661 [100%] at year 1; 83.4% at year 2; 85.9% at year 3; and 78.2% at year 4). Trauma exposure was positively associated with prescription drug problems in unadjusted and age-, sex-, and race-adjusted analyses at follow-up. After accounting for post-traumatic stress disorder (PTSD Checklist-17 Civilian Version) and depression (Patient Health Questionnaire-9) symptoms, trauma exposure was no longer associated with prescription drug problems at all time points (relative risk ratios range 0.91-1.47). These results were robust to different missing data strategies. Trauma exposure was not associated with prescription drug problems over a 4-year follow-up in a prospective cohort study of veterans. Future directions include detailed measures of prescription drug problems and recruitment from community sites.

Background: Cannabis use may adversely impact cardiovascular health through the smoking of particulate matter or through the potential adverse hemodynamic effects of Tetrahydrocannabinol (THC). We assembled a prospective cohort of older Veterans with coronary artery disease (CAD) to examine the effects of cannabis use on: medication use, blood pressure control, and cardiovascular events. Methods: We identified all Veterans 65 to 67 years of age in the Veterans Health Administration (VA) with CAD using national VA data. We included Veterans with at least 1 primary care visit in the prior 2 years. We used text processing to identify mentions of cannabis use (e.g., marijuana, cannabis) in the free text of the medical record and preliminarily categorized patients as potential users and non-users. We then randomly selected patients from each group and performed in-depth telephone health interviews to ascertain cannabis use (e.g., frequency, route), and other important health behaviors and measures, including tobacco and alcohol use, physical activity, depression, and post-traumatic stress disorder. We collected baseline information on blood pressure and comorbid conditions from national VA data. Associations of current cannabis use (past 30 days) with receipt of appropriate medications (i.e., statins, antiplatelets, and beta blockers) were evaluated with multivariable logistic regression. Using linear regression, we also examined associations of current marijuana use with systolic blood pressure and body mass index (BMI). Results: We assembled 792 current cannabis users and 2098 current non-users with CAD. At baseline, the cohort’s mean age was 66 years; 98% were male, 75% white and 18% black. Smoking was the predominant form of cannabis use (90%). The cannabis users had higher use of tobacco cigarettes (42% vs 25%), heavy drinking (31% vs 18%) and other drug use (2.8% vs 1.3%) than non-users (p2 , 95%CI (-1.87, -0.88)) after adjusting for baseline factors. Conclusions: Cannabis use is associated with lower receipt of guideline-recommended cardiovascular medications among Veterans with CAD. Cannabis use is also associated with higher systolic blood pressure, but lower BMI. Future analyses of this prospective cohort will determine whether cannabis use has independent associations with cardiovascular events.

ObjectiveTo develop a tool to assess current (past 30 days) and lifetime marijuana use in older Veterans.SettingUS Veteran’s Affairs Healthcare System.Participants704 older Veterans were screened, 339 completed the initial survey, 100 completed the follow-up.Primary outcome measurePearson’s correlation coefficient to assess strength of association between initial and follow-up survey on measures of current and lifetime marijuana use.ResultsBoth a ‘gram-month’ measure of marijuana smoked in the past 30 days (r=0.83) and a frequency-based measure assessing total number of times smoked in the past 30 days were reliable (r=0.89). Both a simple categorical measure of lifetime use (agreement=85%) and a continuous measure of lifetime use (r=0.82) were reliable.ConclusionsThe Cannabis Assessment Tool offers a reliable assessment of past 30 days and lifetime assessments of smoking cannabis in older adults.

Objective Posttraumatic stress disorder (PTSD) is associated with poor health behaviors, including low utilization of Veteran Health Affairs (VHA) weight loss programs. It is not known if clinically meaningful PTSD improvement is associated with increased use of weight loss programs. Methods Medical record data was obtained from VHA patients who received PTSD specialty care between Fiscal Year (FY) 2008 to FY2012. Clinically meaningful PTSD improvement was defined as ≥20 point PTSD Checklist (PCL) decrease between the first PCL ≥ 50 and a second PCL at least 8 weeks later and within 12 months of the first PCL. Eligible patients, n = 993, were followed through FY2015. Propensity scores and inverse probability of exposure weighting controlled confounding. Cox proportional hazard models estimated the association between clinically meaningful PCL decrease and weight loss clinic utilization. Supplemental analysis compared both PTSD groups vs. no PTSD. Results Patients were 44.8 (SD ±14) years of age, 88.9% male and 66.8% white. Patients with vs. without a clinically meaningful PCL decrease were more likely to use a weight loss clinic (HR = 1.37; 95%CI:1.02–1.85). Among those with a weight loss encounter, PCL decrease was not associated with the number of encounters (RR = 1.13; 95%CI:0.70–1.81). Compared to no PTSD, patients with PTSD improvement had more weight loss encounters. Conclusions Large improvements in PTSD are associated with increased utilization of weight loss programs, and PTSD is not a barrier to seeking weight loss counseling. Research to understand why improvement in PTSD is not related to better weight loss outcomes is needed.