Psychosocial Functioning and Health-Related Quality of Life Associated with Posttraumatic Stress Disorder in Male and Female Iraq and Afghanistan War Veterans: The VALOR Registry

Abstract

Objectives:

Iraq and Afghanistan war veterans suffer from high rates of posttraumatic stress disorder (PTSD). Given the growing number of women in the military, there is a critical need to understand the nature and extent of potential gender differences in PTSD-associated psychosocial functioning and health-related quality of life (HRQOL) in Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) veterans, which has not been studied to date.

Methods:

We used data from a gender-balanced national patient registry of warzone-deployed OEF/OIF veterans (Project VALOR: Veterans After-Discharge Longitudinal Registry) to determine the impact of gender on PTSD-related psychosocial functioning and HRQOL in 1,530 United States Iraq and Afghanistan war veterans (50% female) with and without PTSD. Overall psychosocial functioning was assessed with the Inventory of Psychosocial Functioning (IPF) and mental and physical HRQOL with the Veterans RAND 12-item Health Survey (VR-12) Mental and Physical Component Summary scores, respectively. Stratified linear regression models estimated gender-specific associations, controlling for demographic, deployment, and postdeployment factors. Interaction models tested for significant effect moderation by gender.

Results:

In gender-stratified models, PTSD was strongly associated with higher IPF scores (greater functional impairment), with similar associations by gender. PTSD was also associated with lower Mental Component Summary scores (lower mental HRQOL) in both men and women, with no evidence of effect moderation by gender. PTSD was associated with lower Physical Component Summery scores in women but not men in adjusted models; however, interactions were not significant.

Conclusion:

PTSD among warzone-deployed OEF/OIF veterans is associated with significant impairments in both overall psychosocial functioning and HRQOL, with associations that are largely similar by gender. Findings support the need for thorough and continuous assessment of functional impairment and HRQOL during treatment of PTSD for both male and female OEF/OIF veterans.

Introduction

Posttraumatic stress disorder (PTSD) is a potentially debilitating disorder characterized by re-experiencing of trauma, avoidance, and hyperarousal symptoms in response to a traumatic event.¹ The recent revision of the Diagnostic and Statistical Manual of Mental Disorders criteria (DSM-5) expands the three symptom clusters to four: intrusive thoughts, avoidance, negative alterations in cognitions and mood, and alterations in arousal, and reactivity.² Gender differences in the prevalence and risk of PTSD in the general population are well documented, with studies indicating the prevalence of PTSD to be more than two times higher in women, and that risk of developing PTSD after a traumatic event is more than two times greater in women as compared to men.³ Among the military population of the recent wars in Afghanistan and Iraq—Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF)—PTSD has been called a “signature injury,”⁴ with the overall prevalence of probable PTSD estimated to be 10%–18% in returning servicemen and women.⁵ Studies suggest that returning servicewomen may have a moderately higher risk of postdeployment PTSD than men, though not all studies have found higher risks.⁶

PTSD can have severe impacts on psychosocial functioning (e.g., work, relationships, education) and health-related quality of life (HRQOL).^7,8 Psychosocial functioning and HRQOL are related concepts that broadly encompass multiple dimensions related to physical, mental, emotional and social functioning. HRQOL, in particular, is increasingly used to assess a person's self-perceived impact of health on overall quality of life. Multiple measures have been used to assess HRQOL in general and veteran populations, including the Medical Outcome Study (MOS) Short Forms (SF-12 and SF-36) which provide subscales for the mental and physical component summaries.^9,10 Modified versions of the MOS forms have been previously developed and validated for use in veteran populations.^11,12,13 While a consensus on the best measurements of these domains is lacking, studies consistently show that reduced psychosocial functioning and HRQOL are strongly associated with increased health care utilization and morbidity and mortality and that self-assessed health is a stronger predictor of mortality than many objective measures of health.^14,15,16

To date, studies of PTSD, functional impairment, and HRQOL have been conducted in predominantly male populations. Thus, while it is known that PTSD can have negative impacts on functioning and HRQOL, it is unclear how these impacts compare by gender, and whether the experiences of women veterans with PTSD are comparable or different to their male counterparts. The few studies that have investigated gender differences in PTSD-associated psychosocial functioning and HRQOL were conducted among veterans of previous wars, and displayed little evidence of gender differences.^17

–20 For example, minimal to no gender differences were observed in two separately published studies on PTSD and QOL in male and female Vietnam veterans,^19,20 though effect moderation was not formally assessed. In a more recent study, Magruder et al. studied associations between PTSD severity and HRQOL in 473 male and 40 female veterans seen in U.S. Department of Veteran's Affairs (VA) primary care clinics.¹⁷ They observed negative associations between PTSD symptom severity and all subscales, with associations strongest for mental health, and no significant interactions between gender and PTSD symptom severity. In another study, Schnurr et al. investigated PTSD symptoms and QOL domains in 358 male Vietnam veterans and 203 female veterans from various eras with PTSD, recruited from clinical trials of PTSD treatment.¹⁸ Greater severity of numbing was consistently associated with poorer QOL across all domains (achievement, self-expression, relationships, and surroundings) in men and women; however, little evidence of gender differences was observed in interaction models.

Given the limited data on gender differences in PTSD and HRQOL, it remains unclear whether associations between PTSD and HRQOL and psychosocial functioning differ among male and female OEF/OIF veterans. The experiences of OEF/OIF veterans differ in fundamental ways from veterans of previous wars (e.g., combat exposure, homecoming experience, gender roles) and thus may affect gender differences in PTSD associations, warranting investigation specifically in this population of returning war veterans. Furthermore, stressors experienced by women deployed to Iraq and Afghanistan that may be associated with PTSD and impact HRQOL may differ from male counterparts. These may include combat exposure and post battle experiences, military sexual assault and harassment, interpersonal stressors, social support during and after deployment, and resources for postdeployment adjustment.²¹

Recent reports indicate that mental health outcomes are similar among male and female OEF/OIF veterans despite gender differences in deployment-related stressor and risk factors for PTSD.^22
–24 This suggests that PTSD-associated functioning and HRQOL outcomes may be similar among male and female OEF/OIF veterans. We expected, however, that PTSD-associated functional impairment may be greater in male than female veterans given evidence that symptoms associated with functional impairment (i.e., dysphoria symptoms)²⁵ are more common among male OEF/OIF veterans with PTSD.²⁶ Specifically, men with the same levels of PTSD symptom severity as women have been shown to report more frequent nightmares, emotional numbing, and hypervigilance. We also expected that given lower HRQOL among women in general^27

–30 and some patient populations,^31
–33 the adverse impact of PTSD on HRQOL may be worse among female veterans.

We investigated the impact of gender on associations between PTSD and psychosocial functioning and HRQOL in OEF/OIF veterans deployed to warzones using data from a large, well-characterized cohort with equal gender distribution. As PTSD is commonly seen as associated with physical health problems, we assessed both physical and mental HRQOL.³⁴ Because various demographic factors, deployment-related factors, and postdeployment social support may influence associations between PTSD and the outcomes of interest and vary by gender, we examined gender-stratified associations while hierarchically controlling for covariates. Further, as some postdeployment factors (e.g., depression, employment) are correlated with PTSD and may either confound or mediate associations between PTSD and outcomes of interest, these covariates were considered separately. With the increasing number of combat-exposed women in the military at risk for developing PTSD and the growing number of female veterans, it is critical to understand gender differences in PTSD-associated functioning and HRQOL to adequately allocate treatment and prevention resources for both male and female veterans.

Materials and Methods

Study population

The study population consisted of members of the Veterans After-Discharge Longitudinal Registry (VALOR), a national registry designed to longitudinally assess trajectories and outcomes of PTSD in warzone-deployed OEF/OIF veterans. To accomplish this, we used detailed information collected from (a) self-administered questionnaires, (b) clinician-administered interviews, and (c) the VA's comprehensive electronic medical records (EMR). Details of the VALOR design and methods are published elsewhere.^35
–37 In brief, VALOR consists of 1,649 male and female warzone deployed United States Army and Marine OEF/OIF veterans with and without PTSD. The cohort is a nonprobabilistic convenience sample obtained from recruitment strategies aimed to obtain a gender-balanced, national sample of 1,200 VA health care–seeking OEF/OIF veterans with PTSD and 400 VA health care–seeking OEF/OIF veterans without PTSD. Using lists generated by colleagues at the VA Environmental Epidemiology Service with specified eligibility criteria, 4,391 individuals were contacted by phone and 62.6% consented to participate. Consented individuals were asked to complete a self-administered questionnaire (online or by mail) and were scheduled for a telephone interview with a doctoral-level clinician with specialized training in PTSD assessment. Of consented individuals, 1,649 (60.8%) completed both questionnaire and interview. In total, we recruited 1,213 veterans with ≥2 primary or secondary ICD-9 codes for PTSD (309.81) in the EMR and 436 veterans without PTSD diagnoses in the EMR since 2001. Although EMR diagnoses were used for targeted recruitment purposes, we used structured clinical interviews to assess current and lifetime PTSD, as described below. Concordance status of EMR and interview-based PTSD diagnoses for this cohort are described elsewhere.³⁶ As data collection is ongoing, baseline data collected between 2009 and 2012 were used for current analyses. The study was approved by the Institutional Review Boards of VA Boston Healthcare System and New England Research Institutes, Inc., and the Human Research Protection Office of the U.S. Army Medical Research and Materiel Command.

PTSD

PTSD diagnostic status was assessed by doctoral-level clinicians trained in using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) PTSD module.³⁸ The Structured Clinical Interview for the DSM-IV PTSD module is a validated,³⁹ clinician-administered semistructured interview that assesses the presence of PTSD symptoms in the past month based on DSM-IV criteria. Each symptom was coded as present or absent to determine current (i.e., past 30 days) PTSD. Lifetime PTSD was also assessed, although only current PTSD was used in this analysis. Inter-rater agreement for current PTSD diagnosis was high (κ=0.91).

Psychosocial functioning and HRQOL

Psychosocial functioning was assessed with the self-administered 80-item Inventory of Psychosocial Functioning (IPF) specifically designed to assess functional impairment related to PTSD and other mental disorders experienced by veterans and service members.⁸ This measure yields a grand mean and seven subscale means for functioning in romance, family, friendships, parenting, education, work, and self-care activities. Items are rated from 0 (never) to 6 (always). Each subscale is scored by summing scored items, dividing by the maximum possible score, and multiplying by 100, yielding grand and subscales means of 0–100, with higher scores indicating greater impairment. Because participants may skip subscales that do not apply, the sum of the IPF subscale means is divided by the number of subscales completed. IPF data collected from another sample of 457 veterans showed excellent reliability,⁴⁰ based on the guidelines suggested by Cicchetti,⁴¹ with the overall score demonstrating excellent internal consistency (Cronbach α=0.93), and the IPF subscales demonstrating good internal consistency (Cronbach α=0.80–0.90). The overall IPF score correlates significantly with a number of other self-reported measures of impairment and QOL, such as the World Health Organization Disability Assessment Scale 2.0 (r=0.71), the Medical Outcomes Study 36-Item Short Form for Veterans (r=0.68), the Sheehan Disability Scale (r=0.53–0.57), and the Quality of Life Inventory (r=0.59) (all p<0.001).⁴⁰

We assessed physical and mental HRQOL using the Veterans RAND 12-item Health Survey (VR-12),^12,13 which was developed and modified from the original RAND 12-item MOS Short Form survey (SF-12). The VR-12 is a validated and reliable questionnaire reflecting eight subdomains (self-perceived general health, bodily pain, physical functioning, role limitations due to physical problems, energy/vitality, social functioning, and role limitations due to mental health and emotional problems).¹⁰ The items were used to compute the Physical and Mental Component Summaries (PCS and MCS). The PCS emphasizes subdomains of physical and role functioning, body pain, and general health status over the past 30 days, while the MCS emphasizes vitality, social and emotional functioning, and mental health status over the past 30 days. Items were scored from 0 to 100 and standardized to a mean of 50, with higher scores representing better HRQOL.

Covariates

We selected covariates a priori based on their potential associations with PTSD and HRQOL. Demographic covariates included age and race/ethnicity (white, Hispanic, black, other). We assessed level of warzone exposure with a modified version of the Deployment Risk and Resilience Inventory (DRRI) Combat Experiences and Post-Battle Experiences Scales,⁴² summed as in previous studies.^23,43,44 Military sexual assault was determined by endorsement of the statement, “I experienced unwanted sexual activity as a result of force, threat of harm, or manipulation” as asked on the DRRI Post-Battle Experiences Scale.⁴² Presence of traumatic brain injury (TBI) (no TBI, TBI without loss of consciousness, TBI with loss of consciousness) was assessed via interview with questions reflecting current TBI classification standards⁴⁵ and indicators of brain injury severity.^46,47

Postdeployment social support was assessed by the DRRI Postdeployment Social Support Scale, with lower values indicating lower social support.⁴² Hazardous alcohol use (yes/no) was assessed by the Alcohol Use Disorder Identification Test, defined as ≥8 points.⁴⁸ Anger/hostility was assessed by the Dimensions of Anger Reactions revised short form with higher values indicting greater anger/hostility.⁴⁹ Major depressive disorder, other anxiety syndrome, and panic syndrome were assessed by the Prime-MD Patient Health Questionnaire (PHQ) (all yes/no).⁵⁰ Suicidality within the past month (low, 1–8; medium, 9–16; high,≥17) was assessed during interview via the Mini-International Neuropsychiatric Interview, v.5.0.⁵¹ We also measured socioeconomic variables considered as potential postdeployment variables: married/living with partner (yes/no), employed full-time (yes/no), and education (high school, some post high school, college or beyond).

Statistical analysis

Missing values for DRRI and PHQ scales were replaced with subject-specific means when≤20% of items were missing. We included only participants with complete data on variables of interest, resulting in 1,530 participants and 1,436 participants for IPF and VR-12 analyses, respectively. We assessed the distribution of covariates and outcomes by gender and PTSD. Crude differences were assessed with PROC LOGISTIC for dichotomous variables (PROC CATMOD for multinomial variables) and PROC ANOVA for continuous variables in SAS. Correlations between IPF and VR-12 measures were assessed with Pearson correlation coefficients.

Separate linear regression models estimated associations between PTSD status and functional impairment and HRQOL. For each outcome, we assessed gender-specific associations in crude and adjusted models of increasing complexity in which demographic (age and race/ethnicity), deployment-related variables (warzone exposure, military sexual assault, TBI) (“deployment model”), and postdeployment social support (“postdeployment social support model”) were sequentially added in groups, allowing us to evaluate the impact of the grouped variables on the association between PTSD and each outcome of interest. In addition, because socioeconomics (marital status, employment, education) and comorbid conditions (hazardous alcohol use, anger/hostility, depression, anxiety, panic syndrome, suicidality) may either influence PTSD status or occur downstream of PTSD, these factors were considered separately in additional models (“comorbidities and SES [socioeconomic status] model”).

At each step, interaction models that included the main effects of PTSD and gender, a cross product between PTSD and gender, and covariates were constructed to formally test for significant additive interaction between PTSD and gender. We presented gender-specific parameter estimates for PTSD regardless of the significance of the interaction terms, allowing the influence of covariates to vary by gender. Statistical significance for all testing was considered at the α≤0.05 level. In all analyses, a p-value≤0.05 was accepted for statistical significance. No formal adjustment for multiple testing was performed, but consistency of results across multiple outcomes was emphasized. Analyses were conducted in SAS 9.1.3 (SAS Institute, Cary, NC).

Results

The study sample consisted of 1,530 OEF/OIF Army and Marine veterans (mean age 37.4 years, range 22–69 years), including 958 with PTSD (48% female) and 575 without PTSD (54% female). Average time since returning from last deployment was 5.3 years (range <1–10). Relative to veterans without PTSD, those with PTSD had a greater level of warzone exposure and greater proportions of military sexual assault, TBI, depression, other anxiety, panic syndrome, hazardous alcohol use, and suicidality. Veterans with PTSD also had lower levels of postdeployment social support and were less likely to be employed full-time (Table 1). There were some gender differences—specifically, less full-time employment, more military sexual assault, less TBI, and lower levels of combat exposure and postdeployment social support—among women compared with men. Age, deployment to Iraq, and warzone exposure differed by the combination of PTSD and gender.

Table 1.

Characteristics of Veterans After-Discharge Longitudinal Registry Cohort by Gender and Posttraumatic Stress Disorder Status (n=1,530)

	Men				Women
	PTSD (n=497)		no PTSD (n=267)		PTSD (n=458)		no PTSD (n=308)		p-Values
	No.	%	No.	%	No.	%	No.	%	PTSD	gender	PTSD^ gender*
Age, mean (range)	38.2	(23–64)	37.7	(22–69)	37.9	(22–68)	35.2	(22–65)	<0.01	<0.01	0.03
Race
White	364	73.2	204	76.4	262	57.2	200	64.9	0.21	<0.0001	0.72
Black	50	10.1	23	8.6	101	22.1	52	16.9
Hispanic	62	12.5	27	10.1	66	14.4	41	13.3
Other	21	4.2	13	4.9	29	6.3	15	4.9
Married/living with partner	337	67.8	178	66.7	222	48.5	159	51.6	0.73	<0.0001	0.42
Education
High school or equivalent	74	14.9	32	12.0	32	7.0	15	4.9	0.07	<0.0001	0.39
Some post high school	290	58.4	159	59.6	248	54.1	145	47.1
College or above	133	26.8	76	28.5	178	38.9	148	48.1
Employed full-time for pay	306	61.6	203	76^*	265	57.9	208	67.5	<0.0001	0.01	0.24
Branch^*
Army	421	84.7	225	84.3	439	95.9	291	94.5	0.41	<0.0001	0.51
Marines	38	7.6	20	7.5	12	2.6	8	2.6
Afghanistan	85	17.1	49	18.4	44	9.6	35	11.4	0.38	<0.0001	0.74
Iraq	448	90.1	213	79.8	387	84.5	261	84.7	<0.01	0.55	<0.01
Warfare exposure, mean (SD)	79.5	23.5	62.7	23.1	63.1	21.7	50.8	15.0	<0.0001	<0.0001	0.05
Military sexual assault	11	2.2	5	1.9	132	28.8	32	10.4	0.02	<0.0001	0.06
Traumatic brain injury
No TBI	130	26.2	112	41.9	238	52.0	199	64.6	<0.0001	<0.0001	0.75
TBI without LOC	119	23.9	60	22.5	90	19.7	54	17.5
TBI with LOC	248	49.9	95	35.6	130	28.4	55	17.9
Social support, mean (SD)	48.4	10.0	54.2	11.2	45.8	10.8	53.8	10.9	<0.0001	0.01	0.06
Anger and hostility, mean (SD)	11.7	5.1	7.16	5.0	10.9	5.3	7.2	5.2	<0.0001	0.18	0.15
Hazardous alcohol use	201	40.4	85	31.8	127	27.7	54	17.5	<0.0001	<0.0001	0.37
Major depressive disorder	278	55.9	54	20.2	241	52.6	55	17.9	<0.0001	0.25	0.94
Panic syndrome	249	50.1	53	19.9	228	49.8	64	20.8	<0.0001	0.86	0.77
Other anxiety	215	43.3	39	14.6	202	44.1	48	15.6	<0.0001	0.68	0.88
Suicide risk
Low	422	84.9	250	93.6	399	87.1	288	93.5	<0.0001	0.92	0.83
Moderate	67	13.5	14	5.2	52	11.4	17	5.5
High	8	1.6	3	1.1	7	1.5	3	1.0

Percents exclude missing values.

LOC, loss of consciousness; PTSD, posttraumatic stress disorder; SD, standard deviation; TBI, traumatic brain injury.

Overall IPF score was correlated with PCS (r=−0.28) and MCS (r=−0.62), while PCS and MCS were uncorrelated (r=−0.01). Among men and women, IPF and VR-12 scores were significantly worse in those with PTSD compared with those without, including subscales and subdomains (Table 2). There was little evidence of statistical interactions between PTSD and gender in crude analyses.

Table 2.

Functional Impairment and Health-Related Quality Of Life Measures by Gender and PTSD Status

	Men						Women
	PTSD			no PTSD			PTSD			no PTSD			ANOVA p-values
	n	Mean	SD	n	Mean	SD	n	Mean	SD	n	Mean	SD	PTSD	gender	PTSD^ gender*
IPF total	497	46.8	14.9	267	34.6	15.5	458	46.2	14.1	308	32.8	13.5	<0.0001	0.11	0.46
Romance	312	44.4	17.5	194	33.6	17.2	260	44.3	17.6	210	32.5	17.4	<0.0001	0.61	0.66
Family	441	54.5	19.8	243	42.7	21.4	434	53.7	20.8	293	38.6	21.2	<0.0001	0.03	0.15
Work	306	32.3	16.9	203	22.9	14.7	265	31.6	16.4	208	21.6	13.4	<0.0001	0.33	0.75
Friendship	390	50.7	18.4	223	36.4	19.5	341	49.0	19.3	271	32.9	17.9	<0.0001	0.02	0.41
Parenting	319	33.0	19.7	168	24.8	19.4	270	33.5	19.8	163	21.2	18.0	<0.0001	0.23	0.12
Education	144	36.6	18.2	91	25.1	14.6	170	35.8	16.1	140	24.1	16.7	<0.0001	0.53	0.94
Self-care	488	52.1	18.9	262	39.5	20.0	450	53.5	17.6	304	40.4	18.7	<0.0001	0.25	0.82
VR-12
MCS	462	30.1	10.4	255	41.6	11.5	429	29.3	10.6	290	39.4	10.8	<0.0001	0.01	0.23
PCS	462	42.6	12.2	255	45.8	11.4	429	42.5	12.4	290	48.3	10.3	<0.0001	0.07	0.05
Physical functioning	462	57.5	34.8	255	71.5	32.6	429	53.4	36.2	290	74.3	29.8	<0.0001	0.71	0.06
Role physical	462	49.8	32.3	255	67.0	31.1	429	49.1	31.3	290	70.3	28.5	<0.0001	0.63	0.18
Bodily pain	462	47.2	29.0	255	59.8	29.0	429	47.7	29.6	290	66.8	27.7	<0.0001	0.02	0.04
General health	462	44.0	25.9	255	59.7	26.9	429	46.7	25.1	290	61.8	24.2	<0.0001	0.12	0.77
Vitality	462	31.1	23.0	255	45.4	24.7	429	28.1	22.2	290	41.6	22.4	<0.0001	<0.01	0.66
Social functioning	462	34.4	25.2	255	60.2	29.7	429	32.8	26	290	60.2	29.3	<0.0001	0.48	0.80
Role emotional	462	40.0	25.7	255	66.8	27.2	429	39.4	25.5	290	65.8	26.2	<0.0001	0.50	0.90
Mental health	462	36.2	19.7	255	55.9	22.4	429	34.1	19.1	290	51.9	20.9	<0.0001	<0.01	0.26

IPF, Inventory of Psychosocial Functioning; MCS, Mental Component Summary; PCS, Physical Component Summary; VR-12, Veterans RAND 12-item Health Survey.

PTSD was significantly associated with higher levels of functional impairment (higher IPF) in unadjusted and adjusted models for both men and women, with generally similar magnitudes of association by gender (Table 3). With adjustment for postdeployment social support, both men and women with PTSD had an average increase of 7.63 points on the IPF (95% CI 5.49, 9.78 for men, 5.66, 9.60 for women), equivalent to approximately half a SD in IPF scores for men and women (SD 16.2 among women, 15.3 among men). There was no evidence of effect moderation by gender in interaction models. Additional adjustment for comorbidities and SES further attenuated effect estimates for PTSD among both men and women, but associations between PTSD and IPF remained statistically significant.

Table 3.

Univariate and Multivariable Associations Between PTSD and Functional Impairment and HRQOL by Gender

	Men (n=764)			Women (n=766)			Interaction
	β	95% CI	p-value	β	95% CI	p-value	p-value
Functional impairment (IPF)
Univariate model	12.2	(9.99, 14.5)	<0.0001	13.4	(11.4, 15.4)	<0.0001	0.46
Deployment model	10.9	(8.53, 13.3)	<0.0001	11.7	(9.57, 13.9)	<0.0001	0.77
Postdeployment social support model	7.63	(5.49, 9.78)	<0.0001	7.63	(5.66, 9.60)	<0.0001	0.67
Comorbidities and SES model	2.25	(0.32, 4.17)	<0.0001	4.48	(2.69, 6.27)	<0.0001	0.69
Mental HRQOL (VR12 MCS)^*
Univariate model	−11.5	(−13.2, −9.87)	<0.0001	−10.1	(−11.7, −8.53)	<0.0001	0.23
Deployment model	−10.7	(−12.5, −8.98)	<0.0001	−8.82	(−10.5, −7.10)	<0.0001	0.21
Postdeployment social support model	−7.69	(−8.86, −6.51)	<0.0001	−6.43	(−8.10, −4.77)	<0.0001	0.05
Comorbidities and SES model	−4.79	(−6.21, −3.37)	<0.0001	−2.87	(−4.31, −1.42)	<0.001	0.09
Physical HRQOL (VR12 PCS)^*
Univariate model	−3.26	(−5.09, −1.44)	<0.001	−5.77	(−7.50, −4.04)	<0.0001	0.05
Deployment model	−1.60	(−3.42, 0.23)	0.08	−3.41	(−5.20, −1.62)	<0.001	0.28
Postdeployment social support model	−1.44	(−3.31, 0.42)	0.13	−2.83	(−4.69, −0.97)	<0.01	0.32
Comorbidities and SES model	0.65	(−1.22, 2.51)	0.50	−1.74	(−3.59, 0.11)	0.07	0.15

All multivariable models adjusted for age and race/ethnicity.

Deployment model: Additionally adjusted for warzone exposure, military sexual assault, TBI;

Post-deployment social support model: Deployment model+postdeployment social support;

Comorbidities and socioeconomic status (SES) model: Postdeployment social support model+depression, anxiety, panic disorder, anger, hazardous alcohol use, suicide risk, marital status, education, employment.

n=717 men; n=719 women.

PTSD was also significantly associated with reduced mental HRQOL (lower MCS) in univariate and adjusted models for both men and women (Table 3). While we observed a pattern of larger effect estimates for PTSD in men compared to women, interaction models suggested no effect moderation by gender. In the postdeployment social support model, PTSD was associated with a 6.43 point reduction in MCS (95% CI −8.10, −4.77) among women and a 7.69-point reduction (95% CI −8.86 to −6.51) among men. Adjustment for comorbidities and SES further attenuated effect estimates for both men and women, but associations between PTSD and MCS remained significant.

In univariate models, PTSD was associated with reduced physical HRQOL (lower PCS) in men and women (Table 3), while in the deployment and postdeployment social support models, PTSD was associated with lower PCS in women only. Interaction models did not, however, provide evidence of significant effect moderation by gender. Among women, PTSD was associated with a 2.83 reduction in PCS (95% CI −4.69, −0.97) in the postdeployment social support model. After adjusting for comorbidities and SES, there was no association between PTSD and PCS in women.

Discussion

Among a cohort of male and female OEF/OIF Army and Marine veterans, PTSD was strongly associated with reduced psychosocial functioning in both men and women, even after adjusting for demographic, deployment, and postdeployment factors. Adjusted PTSD–functional impairment associations were largely similar across gender. Similarly, PTSD was associated with lower mental and physical HRQOL generally for both men and women, with associations that were not statistically different by gender.

Very few studies have assessed gender differences in associations between PTSD and functional impairment or HRQOL. Our finding that the associations between PTSD, functional impairment, and HRQOL are largely similar in male and female veterans is consistent with previous studies that assessed gender-specific associations between PTSD status and measures of functioning in male and female Vietnam veterans.^19,20 Our findings are also consistent with previous studies in veterans that assessed additive interactions between gender and PTSD symptom severity or symptom clusters on HRQOL measures in which no or few significant interactions with gender were observed.^17,18 Overall, these data contribute to the growing literature on OEF/OIF veterans that shows a lack of gender differences in mental health outcomes^22
–24 despite differences in deployment-related stressors.

Although interaction models suggested no differences in associations between PTSD and physical HRQOL by gender, it is notable that in stratified models, PTSD was significantly associated with lower PCS in women in unadjusted and multivariable models, and only in an unadjusted model among men. The average deficit of 2.83 PCS points associated with PTSD among women in our study is equivalent to the effect of aging nine years in this cohort. Although the qualitative difference in the gender-stratified models that we observed should not be over-interpreted due to the lack of significant effect moderation, these stratified findings are intriguing and consistent with literature, which suggests that women may be more likely to experience negative PTSD-associated physical health–related functional impairments. For example, a larger, albeit not statistically significant, effect estimate for PTSD-associated limitations in physical functioning was observed among women compared with men in previous studies of Vietnam veterans.^19,20 In addition, Frayne et al. found that in VA health care–seeking OEF/OIF veterans with PTSD, women had more diagnosed medical conditions than male counterparts,⁵² which may relate to poorer physical HRQOL. Moreover, in a study of trauma patients from trauma center hospitals, PTSD was associated with worse scores on the Quality of Well-Being Scale, which measures domains more related to physical than mental HRQOL,⁵³ in women compared with men.⁵⁴ Some studies have also found no associations between PTSD and physical HRQOL in military samples that were primarily male.^55,56

There are study limitations to be considered. As our study sample consisted of veterans seeking VA health care, findings may not extend to veterans outside the VA health care system. In addition, VALOR consists of a self-selected group of individuals, which may bias associations if factors associated with PTSD (e.g., functional impairment) were associated with decisions to participate. Similar proportions of comorbidities observed in VALOR participants as in larger studies of OEF/OIF VA health care–seeking veterans with PTSD^57,58 give little reason to believe, however, that PTSD severity and characteristics among VALOR participants differs, supporting the validity of our findings. Our sample is not a representative sample of all veterans, though, and proportions of PTSD and other covariates in our sample should not be interpreted as indicators of prevalences. Further, our study used DSM IV criteria in the diagnosis of PTSD, rather than the recently revised DSM-5 criteria. It is unlikely however that the associations between PTSD diagnostic status, HRQOL and psychosocial functioning would change with the new criteria given that impairment remains a diagnostic criteria in the DSM-5. A greater limitation of note is that our study did not investigate associations with PTSD symptom severity, as the PTSD Checklist (PCL-M) was collected in only a subset of our sample (59%). Analyses using available PCL-M scores in this subsample however yielded similar findings as with PTSD status. Additional studies of veterans with PTSD using DSM-5 criteria should explore gender-specific associations with HRQOL and psychosocial functioning and further elucidate associations with symptom clusters and PTSD severity. Future studies should also further examine in detail gender-specific associations between PTSD and specific areas of functioning (e.g., relationships, parenting, work, self-care, etc.) and components of mental and physical HRQOL. The cross-sectional study design is another limitation worth noting, as we cannot be certain of the directionality of the association between PTSD and our outcomes. Future analyses of longitudinal data in VALOR will enable us to elucidate temporal associations and evaluate the impact of treatment on PTSD-related functional impairment and HRQOL for both men and women veterans in our sample.

Conclusions

Findings suggest that PTSD among warzone-deployed OEF/OIF veterans is associated with significant impairments in both overall psychosocial functioning and HRQOL, and that associations are largely similar by gender. The 2010 VA/DOD Clinical Practice Guidelines for the management of stress-related disorders recommend a comprehensive assessment of relevant domains of functioning.⁵⁹ Our findings highlight the importance of assessing functional impairment and HRQOL for all warzone-deployed veterans with PTSD, regardless of gender. Thorough assessments should be conducted as a part of clinical care in order to track progress in areas of psychosocial functioning and QOL over time in patients with PTSD. While we primarily assessed overall psychosocial functioning and major subdomains of HRQOL in this paper, the specific types and extent of functional impairment and QOL should be assessed in detail by clinicians among patients with PTSD in order to target areas specifically in need of improvement.⁴⁰

Footnotes

Acknowledgments

Funding for this research was provided by U.S. Department of Defense grants W81XWH-08-2-0100 and 0102.

Author Disclosure Statement

No competing financial interests exist.

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