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Gender Differences in Military Sexual Trauma and Mental Health Diagnoses among Iraq and Afghanistan Veterans with Posttraumatic Stress Disorder

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Gender Differences in Military Sexual Trauma and Mental Health Diagnoses among Iraq and Afghanistan Veterans with Posttraumatic Stress Disorder
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  Original article Gender Differences in Military Sexual Trauma and Mental Health Diagnosesamong Iraq and Afghanistan Veterans with Posttraumatic Stress Disorder Shira Maguen, PhD a , b , * , Beth Cohen, MD, MAS a , b , Li Ren, MS a , Jeane Bosch, MPH a ,Rachel Kimerling, PhD c , Karen Seal, MD, MPH a , b a San Francisco VA Medical Center, San Francisco, California b Department of Psychiatry, University of California, San Francisco, San Francisco, California c VA Palo Alto Health Care System, Menlo Park, California Article history:  Received 11 January 2011; Received in revised form 15 June 2011; Accepted 25 July 2011 a b s t r a c t Objective:  We examined correlates of posttraumatic stress disorder (PTSD), including military sexual trauma (MST), inIraq and Afghanistan veterans. We also compared mental health comorbidities by gender among veterans with PTSD,with and without MST. Methods:  Retrospective data analyses were conducted using Department of Veterans Affairs (VA) administrative datafrom 213,803 Iraq and Afghanistan veterans and the subset diagnosed with PTSD from April 1, 2002, to October 1, 2008.We used descriptive statistics and multivariate logistic regression compared by gender to investigate independentcorrelates and mental health comorbidities associated with PTSD, with and without MST. Results:  Among women with PTSD, 31% screened positive for MST; 1% of men with PTSD screened positive for MST.Among those with PTSD, veterans with MST had more comorbid mental health diagnoses than those without MST.Women with PTSD and MST were more likely to receive comorbid depression, anxiety, and eating disorder diagnoses,and men were more likely to receive comorbid substance use disorder diagnoses. Conclusions:  MST is associated with an increased prevalence of mental health disorders comorbid with PTSD. Betterunderstanding comorbidity patterns will allow for targeted evaluation and treatment of returning veterans with MST.Published by Elsevier Inc. Introduction and Background Over the past 20 years, there has been a twofold increase inthenumberoffemaleveteranswhohaveseparatedfrommilitaryservice and the number of women serving in the military isprojected to continue to increase (Manning, 2008). Currently,women represent 12% of the total number of military personnelwho have served in Operation Enduring Freedom (OEF, princi-pally in Afghanistan) and Operation Iraqi Freedom (OIF)/Opera-tion New Dawn (OND; principally in Iraq; U.S. Department of Defense, 2011). Women comprise 20% of new recruits, 15% of active duty, and 17% of National Guard and Reserve personnel(Manning, 2008). In addition to their increasing numbers,women now serve in military service roles that increase theirexposure to combat and other military service-related risks andconsequently may increase their risk of developing mentalhealth disorders in the postdeployment period. A better under-standing of how mental health conditions and comorbiditiesdifferinmaleandfemaleOEF/OIF/ONDveteranswillbecrucialasthe VA and other health care systems plan for the present andfuture care of this new group of veterans.Therising prevalence and incidenceof service-related mentalhealth disordersin OEF/OIFveteranshasbeenwell-documented,yet we know relatively little about how gender and militaryservice-related risk factors, such as a history of military sexualtrauma (MST), impact risk for mental health disorders in newlyreturning veterans (Hoge et al., 2004; Hoge, Auchterlonie, & Milliken, 2006; Lapierre, Schwegler, & La Bauve, 2007; Seal,Bertenthal, Miner, Sen, & Marmar, 2007; Tanielian et al., 2008).A recent study found that among OEF/OIF veterans seeking VA Supported by Department of Defense Concept Award Grant (Maguen), VAHealth Sciences Research and Development (HSR&D) Career DevelopmentAward (Maguen), and National Institutes of Health grant K23 HL 094765-01(Cohen). *  Correspondence to:Dr. Shira Maguen, San Francisco VA Medical Center, 4150Clement Street (116-P), San Francisco, CA 94121. Phone: (415) 221-4810 x 2511;fax: (415) 379-5562. E-mail address:  Shira.Maguen@va.gov (S. Maguen). www.whijournal.com 1049-3867/$ - see front matter Published by Elsevier Inc.doi:10.1016/j.whi.2011.07.010 Women's Health Issues 22-1 (2012) e61 – e66  care,15% ofwomenand less than 1% of menreporteda historyof MST (Kimerling et al., 2010). Moreover, among both men and women,MSTwas associatedwithincreasedprevalenceof awiderange of mental health disorders, including posttraumatic stressdisorder (PTSD; Kimerling et al., 2010). A history of MST is more common in female than male veterans and is a well-recognizedrisk factor in the development of mental health disorders.Studies of Gulf War I and veterans of prior wars have also foundstrongassociationsbetweenahistoryofMSTandPTSDandothermental health disorders (Hankin et al., 1999; Kang, Dalager,Mahan, & Ishii, 2005; Kimerling, Gima, Smith, Street, & Frayne,2007; Suris, Lind, Kashner, Borman, & Petty, 2004; Suris & Lind,2008; Wolfe, Erickson, Sharkansky, King, & King, 1999). FemaleveteranswithahistoryofMSTwere fi vetoeighttimesmorelikelyto have current PTSD, three times more likely to be diagnosedwith depressive disorders, and two times more likely to be diag-nosedwithalcoholusedisorders,comparedwithfemaleveteranswithout MST (Hankin et al., 1999; Kang et al., 2005; Kimerlinget al., 2007).It is clear that MST is a risk factor for the development of PTSD; however, we know little about how individuals who arediagnosed with PTSD and have an MST history differ from thosewhoarediagnosedwithPTSDanddonotreportahistoryofMST.PTSDiscommonlycomorbidwithothermentalhealthdisorders,such as depression, substance abuse, other anxiety disorders,and eating disorders, yet we do not understand how thesecomorbidities vary in veterans with and without MST or howthey differ by gender (Kulka et al., 1990; Orsillo et al., 1996;Zlotnick et al., 2006).Only one study has examined rates of mental health comor-bidityinOEF/OIFveteranswithPTSD.InananalysisofVArecordsof veterans who served after 9/11, Dedert et al. (2009) foundthat 44% of those diagnosed with PTSD had comorbid currentdepression and 53% had comorbid lifetime substance use disor-ders; there were no differences based on gender. This study didnot include information on history of MST. Given the substantialprevalence of MST among women veterans, there is a need toconsider MSTwhen investigating PTSD comorbidity in both menand women so that evaluation and treatment of veterans withMSTcan be appropriately tailored.We evaluated sociodemographic variables and militaryservicecharacteristicsaspotentialcorrelatesofPTSDinmaleandfemale OEF/OIF veterans seeking VA care nationwide. Amongveterans with PTSD, we examined how comorbid conditionsvaried as a function of MST. Understanding how PTSD andcomorbid mental health conditions differ by gender and MSTstatuswillallowVAandotherhealthcaresystemstobettermeetthe needs of returning OEF/OIF veterans by further honing clin-ical care and research. This is especially critical as more womenveterans return home and  fi nd themselves struggling with themental health consequences of dual exposure to MST andcombat (Corbett, 2007). Methods Study Population Our studysamplewas identi fi ed using the VAOEF/OIF Roster,a databaseof veteranswhohave enrolledinVHAhealthcareandwho have returned from OEF/OIF military service, which wassrcinally created from the Defense Manpower Data Centercontingency tracking system deployment  fi le. The rostercontains demographic and military service variables for OEF/OIFveterans who served within the OEF/OIF combat zones, areas of operation, or were identi fi ed as directly supporting the OEF/OIFmissionoutsidethede fi nedcombatzoneandhaveenrolledinVAcare.OEF/OIFveteranswererequiredtohaveatleastoneprimarycare or mental health visit to a VA facility (using VA Nexus clinicde fi nitions, which includes women ’ s clinics; VA Of  fi ce of Qualityand Performance, 2011) from April 1, 2002, through October 1,2008, and be new users of VA health care to be included in theanalyses. Our study population included 257,043 OEF/OIFveterans, of whom 214,522 were screened fora historyof MST. Asmallpercentageof these individualsdeclinedscreeningand our fi nal sample size included 213,803 veterans (12.4% of these werewomen;  n ¼ 26,527). We subsequently examined the sub-groupof these veterans who received PTSD diagnoses ( n  ¼  74,493).Diagnosisof PTSDorotherMH conditions,as wellas detectionof MST, may have occurred at any point during the study period,given that we were more interested in associations rather thantemporality. It is important to note that MST did not necessarilyoccur during combat, but could have happened at any pointduring military service. Additionally, perpetrators are notnecessarily U.S. military personnel. The study was approved bythe Committee on Human Research, University of California, SanFranciscoandtheHumanResearchProtectionProgramattheSanFrancisco VA Medical Center. Data Source We linked data contained in the OEF/OIF Roster database,which included OEF/OIF veterans ’  demographic and militaryservice information (age, gender, race, marital status, rank,branch, component and deployments), with the VA NationalPatient Care Database, which included information about thedates of VA clinical visits and associated  International Classi  fi ca-tion of Diseases, Ninth Revision Clinical Modi  fi cation  (ICD-9-CM)mental health diagnostic codes. The VA National Patient CareDatabase data are derived from the VA electronic medical recordfrom clinical visits to any of the VA medical centers and/or VAoutpatient clinics nationwide. Study VariablesDemographic and military service variables We used demographic information (age, gender, race/ethnicity, and marital status)and militaryservice characteristics,including component type (active duty versus National Guard orReserve), branch of service, rank (of  fi cer versus enlisted), andnumber of deployments (1 vs.  > 1). Among 213,803 OEF/OIFveterans, demographic and military service characteristics arepresented in Table 1. MST  The VA health care system conducts population-basedscreening for a history of MST in all veterans who present forclinical care to a VA facility using a clinical reminder in the elec-tronic medical record. Each Veteran is asked the following: “ While you were in the military: (1) Did you receive uninvitedand unwanted sexual attention, such as touching, cornering,pressure for sexual favors, or verbal remarks?; (2) Did someoneever use force or threat of force to have sexual contact with youagainst your will? ”  A positive response on either question yieldsa positive MST screen. The VA MST screen has been validatedagainst clinical interview, demonstratingexcellent psychometricproperties with a sensitivity of .92 and speci fi city of .89 for the S. Maguen et al. / Women's Health Issues 22-1 (2012) e61 – e66  e62  fi rstquestion,andasensitivityof.89andaspeci fi cityof.90forthesecond question (McIntyre et al.,1999). Mental health diagnoses Mental health diagnoses associated with clinic visits to VAhealth care facilities were de fi ned as ICD-9-CM diagnoses from296.20 to 311, corresponding to the Diagnostic and  StatisticalManual-FourthEdition (DSM-IV).MentalhealthdiagnosesincludedPTSD (309.81), depression (296.20 – 296.25, 296.30 – 296.35,300.4,and 311), anxiety (300.00 – 300.09, 300.20 – 300.29, and 300.3),adjustmentdisorders(309.0 – 309.9,excluding309.81),alcoholusedisorders (305.00 – 305.03 and 303), substance use disorders(305.20 – 305.93 and 304), and eating disorders (307.1, 307.50 – 307.51, and 307.59). Statistical Analyses Weusedmultivariatelogisticregressionmodelstoexaminetheindependent associations of demographic variables, militaryservice characteristics, and MST with PTSD in 213,803 OEF/OIFveterans seeking VA health care. Given that there were multiplesigni fi cant gender-based interaction terms, we ran each multi-variate logistic regression separately for men and women(Table 1). Further analyses were restricted to the 74,493 veteranswith a PTSD diagnosis. We compared the prevalence of speci fi ccomorbidmentalhealthdiagnosesbetweenmenandwomenwitha PTSD diagnosis,  fi rst through chi-square analysis, and then viamultivariate logistic regression, adjusting for demographic andmilitary service characteristics and using men as the referencegroup (Table 2). Next, we compared the prevalence of speci fi ccomorbid mental health diagnoses between men and womenwith PTSD, strati fi ed by MST status,  fi rst through chi-squareanalysis, and then via multivariate logistic regression, againadjustingfordemographicandmilitaryservicecharacteristicsandusing men as the reference group (Table 3). Finally, we comparedthe prevalence of speci fi c comorbid mental health diagnoses forthosewithandwithoutMST,strati fi edbygender, fi rstthroughchi-square analysis, and then via multivariate logistic regression,adjusting for demographic and military service characteristics,and using those without MST as the reference group (Table 4).Analyses were conducted using SAS (version 9.1; SAS, Inc.,Chicago, IL) and STATA (version 11; STATA Corp., College Station,TX) software. Because of our large sample size, we chose a cutoff   p  of  < .001 for all statistical comparisons. Results Prevalence of MST in Veterans With PTSD Of 74,493 men and women OEF/OIF veterans diagnosed withPTSD, overall,4% ( n ¼ 2,954) reported a historyof MST; however,this prevalence varied by gender. Among female OEF/OIFveterans with PTSD, 31% reported a history of MST ( n  ¼  2,240);1% of male OEF/OIF veterans reported a history of MST ( n ¼ 714). Independent Correlates of PTSD The multivariate logistic regression for PTSD diagnosesincluding both men and women revealed signi fi cant genderinteractions with the following variables: Age, marital status,  Table 1 Demographics and Predictors of PTSD in 213,803 Veterans Seeking VA Health CareVariable Women ( n ¼ 26,527) Men ( n ¼ 187,276) n  % OR 95% CI  n  % OR 95% CIAge group (yrs)16 – 24 (reference) 8,920 34 1 55,176 29 125 – 29 8,844 33 1.12 1.03 – 1.23 55,999 30 0.92 * 0.89 – 0.9530 – 39 5,174 20 1.44 * 1.30 – 1.59 39,379 21 0.97 0.94 – 1.0140 – 71 3,588 14 1.30 * 1.16 – 1.47 36,697 20 0.73 * 0.70 – 0.76Race/ethnicityWhite (reference) 8,938 49 1 86,894 66 1Black 4,656 25 1.01 0.93 – 1.10 15,825 12 1.07 1.03 – 1.11Hispanic 2,842 15 0.91 0.82 – 1.01 20,083 15 0.86 * 0.83 – 0.89Other 1,944 11 0.83 0.72 – 0.95 9,220 7 0.84 * 0.79 – 0.89Marital statusMarried (reference) 7,695 30 1 85,723 47 1Never married 13,010 50 0.90 0.83 – 0.98 76,220 42 0.72 * 0.69 – 0.74Divorced/separated/widowed 5,178 20 1.08 0.98 – 1.19 20,544 11 1.12 * 1.08 – 1.17Component typeActive duty (reference) 15,929 60 1 103,429 55 1Reserve/National Guard 10,598 40 0.96 0.88 – 1.03 83,822 45 0.63 * 0.61 – 0.64Branch of serviceArmy (reference) 17,199 65 1 121,394 65 1Marine 1,158 4 0.92 0.77 – 1.10 30,593 16 0.92 0.88 – 0.95Navy 4,298 16 0.38 * 0.34 – 0.44 20,627 11 0.31 * 0.29 – 0.32Air Force 3,861 15 0.41 * 0.36 – 0.46 14,534 8 0.25 * 0.23 – 0.26RankEnlisted (reference) 24,951 94 1 178,423 95 1Of  fi cer 1,576 6 0.68 * 0.58 – 0.79 8,828 5 0.47 * 0.44 – 0.50Number of deployments1 (reference) 18,543 70 1 119,634 64 1 > 1 7,984 30 1.16 * 1.08 – 1.26 67,617 36 1.15 * 1.12 – 1.18MST statusNo MST (reference) 4,175 16 1 1,273 1 1MST 22,352 84 4.17 * 3.82 – 4.56 185,978 99 2.69 * 2.33 – 3.12 Note:  Table represents multivariate logistic regression and odds ratios represent adjusted odds ratios. *  p < .001. S. Maguen et al. / Women's Health Issues 22-1 (2012) e61 – e66   e63  component type, branch, of  fi cer vs. enlisted status, and MST(all  p  <  .001). Consequently, we strati fi ed the multivariatelogisticregressionmodelforPTSD diagnosesbygender(Table1).Among 213,803 male and female OEF/OIF veterans seeking VAhealth care, MST was associated with a nearly threefold increaseinoddsof PTSDformen,andoverafourfoldincreaseforwomen.Other variables that were signi fi cantly associated with PTSDincludedbeingaveteranoftheArmy(versusNavyandAirForce),havingbeenenlisted(versusanof  fi cer), andhavinghad multipledeployments (versus a single deployment). Among women,beingage30yearsorolderwasassociatedwithPTSD,whereasinmen, risk for PTSD decreased with advancing age. Comorbid Mental Health Diagnoses in Veterans With PTSD We examined the prevalence of comorbid mental healthdiagnoses between women and men in the 74,493 OEF/OIFveterans with PTSD (Table 2). Female OEF/OIF veterans withPTSD ( n ¼ 7,255) were more likely than their male counterpartsto have clinical presentations of comorbid depression, otheranxiety disorders, and eating disorders. Of women withPTSD, 70% also were diagnosed with depression. Male OEF/OIFveterans with PTSD ( n  ¼  67,238) were more likely than theirfemale counterparts to have clinical presentations of comorbidalcohol and other substance use disorders; one quarter of menwith PTSD had comorbid alcohol use disorders. Comparedwith women, men were more likely to have received a singlemental health diagnosis, whereas women were more likelyto have received three or more comorbid mental healthdiagnoses. Gender Comparisons of Comorbid Mental Health Diagnoses,Strati  fi ed by MST  Female OEF/OIF veterans with PTSD and a history of MSTwere more likely to have clinical presentations of comorbiddepression, anxiety, and eating disorders than their male coun-terparts with PTSD and MST (Table 3). Three quarters of womenwith PTSD and MST had comorbid depression, more than onethird had another anxiety disorder, and 4% were diagnosed witheating disorders. MST Comparisons of Comorbid Mental Health Diagnoses,Strati  fi ed by Gender  Among female OEF/OIF veterans with PTSD, MST was signif-icantly associated with comorbid depression, substance use,anxiety,alcoholuse,andeatingdisorders(Table4).MaleOEF/OIFveterans with PTSD and a history of MST were more likely tohave clinical presentations of comorbid depression, andsubstance use, but did not differ on the other comorbid diag-noses. Women and men with a history of MST were more likely  Table 3 Mental Health Diagnosis in 74,493 OIF/OEF Veterans Who Received PTSD Diagnoses with and without a History of MST by GenderPTSD with MST PTSD without MSTWomen( n ¼ 2,240)Men( n ¼ 714)Women vs. Men Women( n  ¼ 5,015)Men( n ¼ 66,524)Women vs. Men n  %  n  % AOR  * 95% CI  n  %  n  % AOR  * 95% CIMental health diagnosisDepression 1,684 75 y 460 64 1.71 y 1.36 – 2.16 3,381 67 y 35,899 54 1.67 y 1.55 – 1.80Substance use 193 9 122 17 y 0.43 y 0.31 – 0.60 304 6 7,934 12 y 0.45 y 0.39 – 0.51Adjustment disorder 638 29 211 30 0.99 0.78 – 1.25 1,453 29 18,273 28 1.00 0.93 – 1.08Anxiety 941 42 y 234 33 1.49 y 1.19 – 1.86 1,860 37 y 20,180 30 1.30 y 1.21 – 1.40Alcohol use disorder 361 16 195 27 y 0.48 y 0.37 – 0.62 595 12 16,762 25 y 0.36 y 0.33 – 0.40Eating disorders 88 4 y 5 1 9.66 y 2.34 – 39.99 67 1 y 190 0.3 4.98 y 3.49 – 7.11Multiple mental health diagnoses1 277 12 115 16 0.69 0.51 – 0.93 820 16 14,747 22 y 0.75 y 0.68 – 0.812 716 32 229 32 1.02 0.81 – 1.28 1,824 36 y 22,079 33 1.17 y 1.09 – 1.26  3 1.247 56 370 52 1.18 0.96 – 1.47 2,371 47 29,698 45 1.03 0.96 – 1.10 *  Multivariate models predicting mental health diagnoses by gender adjusted for age, race, marital status, rank, branch, component and multiple deployments. y  p < .001.  Table 2 Comorbid Mental Health Diagnoses in 74,493 OEF/OIF Veterans with PTSD Diagnoses by GenderWomen ( n ¼ 7,255) Men ( n ¼ 67,238) Total ( n ¼ 74,493) Women vs. Men n  %  n  %  n  % AOR  * 95% CIMental health diagnosisDepression 5065 70 y 36359 54 41424 56 1.89 y 1.76 – 2.00Substance use 497 7 8056 12 y 8553 12 0.48 y 0.43 – 0.54Adjustment disorder 2091 29 18484 28 20575 28 1.02 0.96 – 1.09Anxiety 2801 39 y 20414 30 23215 31 1.40 y 1.32 – 1.49Alcohol use disorder 956 13 16957 25 y 17913 24 0.41 y 0.37 – 0.44Eating disorders 155 2 y 195 0.3 350 1 7.74 y 5.85 – 10.23Multiple mental health diagnoses1 1097 15 14862 22 y 15959 21 0.67 y 0.62 – 0.732 2540 35 22308 33 24848 33 1.10 1.03 – 1.18  3 3618 50 y 30068 48 33686 45 1.15 y 1.09 – 1.22 Note:  Multiple mental health diagnoses only include diagnoses listed in this table, including PTSD. *  Multivariate models predicting mental health diagnoses by gender are adjusted for age, race, marital status, rank, branch, component, and multiple deployments. y  p < .001. S. Maguen et al. / Women's Health Issues 22-1 (2012) e61 – e66  e64  to have three or more comorbid mental health diagnosescompared with their counterparts without MST. Discussion To our knowledge, this is the  fi rst study to examine genderdifferences in PTSD and mental health comorbidities amonga national sample of OEF/OIF veterans in VA health care. Givenreports that OEF/OIF veterans with PTSD are at high risk of comorbid mental health conditions, functional dif  fi culties,suicide, and problems with physical health (Kang & Bullman,2008; Kang & Hyams, 2005; Tanielian et al., 2008), it is impor-tant to identify factors associated with PTSD, such as MST, and toexamine comorbid mental health problems. Understanding howthese risk factors and comorbidities differ in male and femaleveterans can help us to better target evaluation and early inter-ventiontopreventchronicmentalillnessandrelateddysfunction.We found that 31% of OEF/OIF female veterans with PTSD hadscreened positive for a history of MST. This is a substantiallyhigher prevalence than found among the general population of female OEF/OIF VA patients, inwhich 15% report MST (Kimerlingetal.,2010).Afteradjustingfordemographicandmilitaryservicecharacteristics, OEF/OIF female veterans with MST were morethan four times more likely to develop PTSD compared withwomen without MST. This rate is similar to prior  fi ndings byKang et al. (2005), who reported that female Gulf War I veteranswith a history of MST were  fi ve times more likely to developPTSD than their female counterparts without MST; this rate alsoreplicates fi ndingsbyKimerlinget al.(2010) inOEF/OIFveterans.When examining comorbid mental health conditions inwomen and men with PTSD, we found that rates of all mentalhealth conditions were higher than those previously reportedamong a general sample of OEF/OIF veterans who sought care atVAfacilities(Maguen,Ren,Bosch,Marmar,&Seal,2010).Womenwith PTSD were more likely to be diagnosed with comorbiddepression, other anxiety disorders, and eating disorderscompared with men. Men with PTSD were more likely to bediagnosed with comorbid alcohol and substance use disorderscompared with women. Prior researchers have postulated thatalcohol and substance abuse may represent an effort to self-medicate avoidance or hyperarousal symptoms associated withPTSD (Bremner, Southwick, Darnell, & Charney,1996; Chilcoat & Breslau, 1998), although it is not understood why this woulddifferentially impact male veterans.These  fi ndings depart from the one known prior study of newly returning OEF/OIF veterans examining issues of comor-bidity that found no gender differences in rates of comorbiddisorders (Dedert et al., 2009). Indeed, our  fi ndings related tocomorbidity are more consistent with research conducted withveterans of prior eras. Among Vietnam veterans with PTSD, menwere more likely to be diagnosed with alcohol use and othersubstance use disorders compared with women veterans (Kulkaet al., 1990).We also found that women with PTSD and MST were morelikely to be diagnosed with depression, other anxiety disorders,and eating disordersthan menwith PTSD and MST. Although thepatternwas similar forwomenand menwithPTSDwithout MST,womenwith PTSD and MST had higher rates of all mental healthcomorbidities examined, compared with women with PTSDwithoutMST.ItisimportanttonotethatthedifferencesbetweenwomenwithPTSDwithandwithoutMSTaremainlyinmagnitudeof effect rather than in overall trends or patterns. For example,although75%ofwomenwithPTSDandMSTwerediagnosedwithdepression, 67% of women with PTSD without MST were alsodiagnosedwithdepression.Therefore,amongwomenwithPTSD,depression is a common comorbid condition. Furthermore, 4% of womenwithPTSDandMSTwerediagnosedwitheatingdisorders.Given that eating disorders can have serious, life-threateningcomplications, the relationship between PTSD and eating disor-ders is a potentially important area for further research.It also is important tocontextualize these fi ndings in terms of whatwegenerallyknowaboutgenderdifferencesamongfemaleveterans and military personnel returning from deployments.Morespeci fi cally,womendemonstratehigherratesofdepressionand eating disorders compared with men, and men generallydemonstrate higher rates of alcohol and substance use disorders(Lapierre et al., 2007; Seal et al., 2007; Tanielian et al., 2008).Our  fi ndings should be interpreted in light of several limita-tions.First,thisstudywasconductedwithapopulationofveteranswhohadatleastonevisittoaVAhealthcarefacility;therefore,ourresultsshouldnotbegeneralizedtoallOEF/OIFmilitarypersonnelor veterans. More speci fi cally, we needed to limit our sample tothose who had at least one VA visit to primary care or mentalhealth clinics, because this is where mental health screens occurand diagnoses are made; consequently those who never soughtVA care are not included in this study and generalizibility islimited.Second,weselectedapopulationofveteranswhoservedinsupportofOEF/OIF;therefore,theseresultsmaynotgeneralize  Table 4 Mental Health Diagnosis in 74,493 OIF/OEF Veterans Who Received PTSD Diagnoses with and without a History of MST Within GenderWomen MenMST( n ¼ 2,240)No MST( n ¼ 5,015)MST vs. No MST MST( n ¼ 714)No MST( n ¼ 66,524)MST vs. No MST n  %  n  % AOR  * 95% CI  n  %  n  % AOR  * 95% CIMental health diagnosisDepression 1,684 75 y 3,381 67 1.54 y 1.34 – 1.77 460 64 y 35,899 54 1.56 y 1.29 – 1.89Substance use 193 9 y 304 6 1.28 1.01 – 1.63 122 17 y 7,934 12 1.35 1.04 – 1.75Adjustment disorder 638 29 1,453 29 1.10 0.96 – 1.26 211 30 18,273 28 1.05 0.98 – 1.12Anxiety 941 42 y 1,860 37 1.30 y 1.14 – 1.47 234 33 20,180 30 1.12 0.92 – 1.36Alcohol use disorder 361 16 y 595 12 1.39 y 1.16 – 1.65 195 27 16,762 25 1.14 0.92 – 1.40Eating disorders 88 4 y 67 1 2.61 y 1.76 – 3.88 5 1 190 0.3 1.53 0.38 – 6.24Multiple mental health diagnoses1 277 12 820 16 y 0.67 y 0.56 – 0.81 115 16 14747 22 y 0.73 0.57 – 0.942 716 32 1824 36 y 0.80 y 0.70 – 0.91 229 32 22079 33 0.95 0.78 – 1.15  3 1247 56 y 2371 47 1.48 y 1.31 – 1.67 370 52 y 29698 45 1.27 1.06 – 1.53 *  Multivariate models to predict MH DX by gender adjusted for age, race, marital status, rank, branch, component, and multiple deployments. y  p < .001. S. Maguen et al. / Women's Health Issues 22-1 (2012) e61 – e66   e65
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