Preventive Health Behaviors, Health-Risk Behaviors, Physical Morbidity, and Health-Related Role Functioning Impairment in Veterans with Post-Traumatic Stress Disorder

Military Medicine, Jul 2004 by Buckley, Todd C, Mozley, Susannah L, Bedard, Michele A, Dewulf, Anne-Cecile, Greif, Jennifer

An examination of the relationships between health behaviors (preventive and risk-related), physician-diagnosed medical problems, role-functioning impairment because of physical morbidity, and post-traumatic stress disorder was conducted on a large cohort of consecutive treatment-seeking cases (N = 826) presenting to an outpatient Veterans Affairs post-traumatic stress disorder clinic. Results revealed that the sample rates of several medical conditions were markedly elevated when compared with general population rates for men of a comparable age. The rates of smoking and other behavioral risk variables were greater than rates among men in the general population. Moreover, the majority of the sample did not engage in preventive health behaviors such as exercise and medical screening at levels consistent with health care guidelines. Physical role functioning indices of the SF-36 reveal greater role-functioning impairment because of physical morbidity in this psychiatric sample relative to the age adjusted general population norms. The health care implications of these data are discussed, as are areas for future research.

Introduction

Post-traumatic stress disorder (PTSD) is among the most prevalent of psychiatric disorders according to recent epidemiological data.1 In addition, evidence suggests that PTSD is among the costliest psychiatric disorders in terms of economic burden on the health care system.2 It has been determined that, in large measure, this latter finding is driven by a higher than expected use of health care systems for physical morbidity among individuals with PTSD relative to the general population and other psychiatric groups.3 Such findings underscore the need for research to identify the reasons behind the correlation between PTSD, physical morbidity, and health care use.

In recent years, several empirical papers have emerged suggesting that chronic PTSD is associated with poor physical health. For example, individuals with PTSD report a greater number of specific symptoms (back pain) and diagnostic conditions (hypertension) relative to groups without PTSD.4 In addition, physician-diagnosed medical problems are more frequent among those who carry a diagnosis of chronic PTSD relative to those who do not.5 Regarding biological indicators or correlates of health, chronic PTSD has been associated with elevated resting heart rate,6 incidence of nonfatal myocardial infarction,7 low heart rate variability,8 elevated basal catecholamine levels,9 and abnormal hypothalamic-pituitary-adrenal functioning.10 Such effects have been demonstrated across a variety of independent laboratories, and many of these biological measures are statistical risk factors for premature death. Finally, research suggests that relative to nonpsychiatric controls and other psychiatric groups, PTSD is associated with elevated rates of role-functioning impairment because of physical morbidity. ' '

These areas of investigation point in unison to the fact that having a diagnosis of chronic PTSD is a risk factor for physical morbidity and that the effect does not seem constrained to one organ system.12 Recent studies have begun searching for causal mechanisms that might account for such effects. Some researchers have hypothesized that repeated responding to Stressors with augmented and sustained sympathetic nervous system output places individuals with PTSD at undue risk for physical morbidity.6 Indeed, several laboratory studies suggest that individuals with PTSD show augmented sympathetic responses to stress challenges relative to control groups.13 Such findings suggest that potentiated and sustained responding to stress in the sympathetic nervous system facilitates disease processes. Alternatively, some have proposed that the documented relationship between PTSD and certain adverse health behaviors (e.g., smoking) might provide a mediational link between FfSD and physical health. For example, PTSD is associated with high rates of alcohol abuse/dependence. ' It is well documented that alcohol consumption of greater than three drinks per day is associated with increased blood pressure and heart rate, as well as increased mortality from coronary artery disease and stroke.14 PTSD is also associated with markedly elevated rates of nicotine use relative to the general population.15 These influences point to ways in which PTSD can have an indirect impact on cardiovascular health.

The noted studies notwithstanding, there are some deficits in the current literature regarding PTSD and health behaviors. Specifically, most studies in this area have had a singular focus (e.g., smoking) and/or have relied on self-reporting and relatively small sample sizes.16 Moreover, most of these studies have focused on adverse health behaviors without examining the frequency of preventive lifestyle behaviors such as exercise. Thus, the relationship of PTSD to preventive health behaviors is unknown.

We are not aware of any studies that have examined multiple indices of health-risk behaviors, physician-diagnosed medical problems, preventive health behaviors, and role-functioning limitations associated with physical morbidity in the same sample of PTSD patients diagnosed via reliable structured interview (e.g., Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders [DSM-IV)).17