Mental Health and Cognition in Women Veterans Enrolled in the Health of Vietnam Era Veteran Women’s Study (HealthViEWS)

Abstract

Objective:

This analysis explored relationships between mental health symptoms and conditions and cognitive function in a cohort of Vietnam-era women veterans from the Health of Vietnam Era Veteran Women’s Study (HealthViEWS).

Methods:

Vietnam-era women veterans completed a mail survey assessing self-reported symptom severity of posttraumatic stress disorder (PTSD) and depression. A telephone-based structured interview assessed mental health conditions and cognitive function (telephone interview for cognitive status [TICS]). Participants were categorized using a TICS threshold of ≤29 to designate possible cognitive impairment versus nonimpaired. Separate logistic regression models were used to determine associations between possible cognitive impairment and each self-reported and interviewer-rated assessment of PTSD and depression while adjusting for age, education, race, marital status, and wartime service location.

Results:

The sample consisted of 4,077 women veterans who were ≥60 years old and completed the TICS. Of these women, 7.20% were categorized with possible cognitive impairment. Logistic regression models indicated that self-reported PTSD and depression symptom severity were each significantly associated with higher odds of possible cognitive impairment (adjusted odds ratios [aOR]: 1.03 [95% confidence interval [CI]: 1.02–1.04] and 1.07 [95% CI: 1.04–1.09], respectively). Women veterans with a probable diagnosis of depression had higher odds of possible cognitive impairment compared to those without depression (aOR: 1.61 [95% CI: 1.07–2.42]). No association was found for probable diagnosis of PTSD.

Conclusions:

Although further examination remains necessary, results suggest that Vietnam-era women veterans with self-reported PTSD and depression symptom severity or a probable diagnosis of depression may benefit from screening of cognitive function to inform clinical care.

Introduction

In the United States, the distribution of the veteran population is heavily skewed toward older adults, with nearly two-thirds of veterans aged 55 years and older (median age is 64 years).¹ As this group ages, the occurrence of cognitive impairment, an age-related health problem, will likely increase. Cognitive impairment is a significant public health concern in that it is associated with decreased quality of life^2,3 increased health care costs, and other comorbid disorders.^4,5 Thus, investigating risk factors associated with cognitive impairment later in life has important implications for the care of the rapidly aging veteran population.

Over and above normal age-related changes in cognition, several risk factors unique to military service (e.g., combat deployment, exposure to warfare, and so on) are associated with changes in cognitive function among veterans.^3,6 Specifically, posttraumatic stress disorder (PTSD) and depression, two commonly reported mental health disorders among veterans, are associated with concurrent performance deficits across multiple cognitive domains (e.g., attention, executive function, memory), relative to healthy controls.^7,8 Furthermore, there is evidence suggesting that cognitive impairment may persist among some individuals despite treatment and/or remission of anxiety and depression symptoms,^7,9,10 demonstrating potential long-term effects of these two mental health disorders on cognition. Multiple systematic reviews and meta-analyses have found that these two mental health disorders coincide with cognitive impairment and, in some cases, may precede late-life cognitive changes.^9

–15

Among veterans, PTSD and depression often persist long after military service with some studies demonstrating a worsening of symptoms with time.^16

–19 In addition, the lifetime prevalence of these disorders is much higher among veterans in comparison to the general population,^3,16 indicating that veterans may have elevated mental health risk factors for cognitive impairment beyond normal age-related changes. To date, most of the research on the effects of PTSD and depression following military service on late-life cognitive function has been conducted among men, likely reflecting the fact that most service members are men. However, women also serve in the military, and the rate of women enlisting and commissioning as officers has increased in recent years, further adding to the importance of examining this understudied population.²⁰

Although the field of research on women veteran’s health is expanding, there continues to be knowledge gaps, particularly regarding cognitive function and comorbid disorders.²¹ In the general population, associations have been found between cognitive impairment and hormonal,^22,23 genetic,^24,25 and psychosocial factors²⁶ in women. In addition, women tend to have higher rates of dementia and other forms of cognitive impairment than men.²⁷ There are multiple explanations for this observation in the literature (i.e., women live longer, survival of men with lower rates of cardiovascular disease, gender differences in immune system functioning),^28
–30 thus emphasizing the need for further examining factors associated with late-life cognition in women veterans. Indeed, there is evidence demonstrating the potential long-term health consequences of wartime stressors that may persist years after military service among women veterans.³¹ For example, previous examinations of general health symptoms in Gulf War-era women veterans have consistently identified links between military service and symptoms of mood/cognition (e.g., depression, anxiety, and memory/concentration problems),^31,32 with greater symptom burden observed among women deployed to the Gulf War theater compared with women deployed elsewhere.^33,34

There are few epidemiological studies that have examined the link between mental health symptoms and late-life cognition among women^12,14 and even fewer among women veterans.³⁵ These studies utilized in-person cognitive testing or International Classification of Diseases (ICD) codes to identify participants with mild cognitive impairment or dementia. The use of cognitive screenings may expand on prior studies supporting future research on cognitive function and relationships with mental health symptom severity in the understudied population of older women veterans. Because self-report mood screening measures have been associated with over- or under-reporting depending on the context,³⁶ the current examination also included a structured diagnostic interview for facilitation of psychiatric treatment planning and formulation of clinical interventions. Therefore, this analysis aimed to investigate the extent to which self-reported PTSD and depression symptom severity and probable diagnoses of PTSD and depression are associated with late-life cognitive function among a population of Vietnam-era women veterans.

Materials and Methods

Study participants

Data for the present study were obtained from the Department of Veterans Affairs (VA) Cooperative Study Program #579, The Health of Vietnam Era Veteran Women’s Study (HealthViEWS), which was a large epidemiological investigation examining the long-term health effects of military service among women veterans who served during the Vietnam Era.^16,37 Initial cohort identification, recruitment, and data collection procedures used in HealthViEWS have been described in detail elsewhere.^16,37 Briefly, the initial cohort of women veterans serving during the Vietnam Era was identified from multiple data sources, including paper and electronic military personnel records and existing epidemiological cohorts previously abstracted by other studies.^37

–40 Duplicates across data sources were removed, and mismatching information was sent to the National Personnel Record Center (U.S. National Archives and Records Administration, St. Louis, Missouri), where military personnel files were abstracted to determine eligibility and location of service. Eligibility criteria for the HealthViEWS included women veterans having served in the U.S. Armed Forces (e.g., Army, Navy, Air Force, or Marine Corps) for a minimum of 30 days between July 4, 1965 and March 28, 1973.¹⁶

There were 8,742 women veterans who were alive at the time of data collection (between May 16, 2011 and August 5, 2012), were eligible to participate in HealthViEWS, and were locatable.¹⁶ There were 3,478 (39.8%) who did not respond, 619 (7.1%) who completed only the mail survey, and 426 (4.9%) who completed only the telephone interview, resulting in a total of 4,219 women Veterans (48.3%) who completed both the mail survey and telephone interview. There were a few minor differences observed between responders who completed both the mail survey and telephone interview and nonresponders who failed to complete one or both forms of data collection. Specifically, responders were more likely to be younger at enlistment (≤ 21 years: 64.7% versus 57.9%), a nurse (70.7% versus 65.4%), and served in Vietnam (46.7% versus 35.7%) compared with nonresponders.¹⁶

Given the prevalence of neuroanatomical age-related changes that occur after age 60,⁴¹ participants ≥60 years old who completed both the mail survey and telephone interview were selected for analysis, resulting in a sample of 4,134 women veterans. Of these women, 4,077 had completed the telephone-based cognitive assessment, thus constituting the analytic cohort for this article.

Procedures

All eligible women veterans identified through the process outlined above were mailed an introductory packet that included study information and an opt-out postcard. A secondary packet containing additional study materials (e.g., survey, stamped return envelope, and another opt-out postcard) was mailed to those who did not opt out. Those interested in participating in the study completed the survey and returned it via a stamped return envelope. Nonresponders were contacted further via additional mailings. Women who returned the mail survey and women who had telephone numbers available (but did not complete the mail survey) completed the telephone interview. The telephone interview included a structured psychiatric diagnostic interview and a screen for cognitive impairment. Compensation for completing both the mail survey and telephone interview was $150 ($75 per component). This study was approved by the VA’s Central Institutional Review Board with a waiver for written informed consent, given the nature of the study; however, verbal consent was obtained during the telephone interview.

Measures

Self-reported measures

The following measures were completed as part of the mail survey:

PTSD checklist for DSM-IV-Civilian version⁴²

The PTSD checklist for DSM-IV-Civilian version (PCL-C) is a 17-item self-report measure that assesses severity of PTSD symptoms corresponding to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. Respondents rated how much each symptom had bothered them for the past 30 days. Total scores can range from 17 to 85, with higher scores representing greater PTSD symptom severity.

Patient health questionnaire-9⁴³

The Patient health questionnaire-9 (PHQ-9) is a brief 9-item self-report measure of depression symptoms corresponding to DSM-IV criteria. Respondents reported the frequency of depressive symptoms for the past 2 weeks. Total scores can range from 0 to 27, with higher scores indicative of greater severity of depression symptoms.

Demographics

Military service records were used to obtain date of birth (to calculate age at study enrollment), race, and wartime service location, whereas education level and marital status were self-reported on the mail survey. These demographic variables have been found to be highly correlated with cognitive performance^44

–47 and were controlled as covariates in the analyses. In addition, a previous HealthViEWS report demonstrated that wartime stress exposures were significantly greater for women deployed to the Vietnam theater compared with those serving in the United States;¹⁶ therefore, wartime service in Vietnam was controlled as a covariate.

Telephone-administered measures

The measures described below were completed as part of the telephone interview:

Composite international diagnostic interview version 3.0⁴⁸

The Composite international diagnostic interview version 3.0 (CIDI) is a structured diagnostic interview for assessing psychiatric disorders as defined by the DSM-IV and the ICD-10 Diagnostic Criteria for Research.⁴⁹ The CIDI is intended for use in epidemiological studies, as well as for clinical research purposes, and can be administered by trained lay interviewers.⁵⁰ The CIDI assesses both lifetime and current (within the past year) diagnoses of a broad range of psychiatric disorders. For this analysis, only current diagnoses of PTSD and depression were used to align with the timeframe of the self-reported assessments of PTSD and depression symptom severity.

Telephone interview for cognitive status⁵¹

The telephone interview for cognitive status (TICS) is a brief screening measure for global functioning consisting of 11 items within the following cognitive domains: 1) basic orientation (person, time, and place), 2) attention/working memory (counting backwards, subtractions), 3) verbal memory (immediate recall of a 10-item word list), 4) language (comprehension, repetition, naming, following directions), and 5) concept formation (word opposites).^52

–55 Overall scores can range from 0 to 41, with lower scores representing worse cognitive function. TICS scores have been found to be positively correlated (r = 0.94) with the Mini-Mental State Examination,⁵¹ one of the most widely used cognitive screening and monitoring measures for dementia.

In the HealthViEWS study, the distribution of the TICS scores was negatively skewed with very few participants scoring in the mildly to severely impaired ranges associated with a diagnosis of dementia (n = 63; defined as scores ≤25). Therefore, overall scores on the TICS were dichotomized into two categories using a threshold of ≤29 to designate possible cognitive impairment versus nonimpaired. The threshold of ≤29 was demonstrated in a meta-analysis as a TICS cutoff suggestive of possible cognitive impairment/dementia.^55,56

Statistical analyses

All analyses were conducted using SAS statistical software for Windows, version 9.4 (SAS Institute, Inc, Cary, NC) and incorporated survey weights that accounted for nonresponse and differences between those locatable and not locatable during data collection.¹⁶ Weighted participant characteristics were reported as means (SEs) and percentages (95% confidence intervals [CIs]), as appropriate. Descriptive statistics were used to evaluate differences between the cognitive function groups using Chi-square tests for categorical variables and independent samples t test for continuous variables. Logistic regression analysis was used to examine the relationship between possible cognitive impairment (dependent variable) and each assessment of PTSD and depression in separate models. Symptom severity scores were assessed as continuous variables, whereas the CIDI probable diagnoses of PTSD and depression were treated as dichotomous variables (yes/no). Unadjusted and adjusted odds ratios (aORs) of possible cognitive impairment were reported with 95% CIs. In the adjusted models, ORs were adjusted for age (years), level of education (less than a Bachelor’s degree versus Bachelor’s degree or higher), race (White versus non-White), marital status (divorced/separated/widowed and never married versus married/living with a partner), and wartime service location (Vietnam versus elsewhere). Cases with missing data were removed from analyses. For all analyses, p values < 0.05 were statistically significant.

Results

Demographic characteristics

Table 1 displays the weighted participant characteristics categorized using a TICS threshold of ≤29 to designate possible cognitive impairment versus nonimpaired. Among the 4,077 participants, there were 263 participants (weighted percentage = 7.20%) who were categorized with possible cognitive impairment and 3,814 (weighted percentage = 92.80%) participants categorized as nonimpaired. Overall, participants were on average 67.62 years of age, served in the military for approximately 8.33 years, and were predominantly White (90.88%), had a bachelor’s degree or higher (66.21%), and worked as a nurse during their military service (67.85%). Approximately 11.77% of the participants had a probable diagnosis of PTSD, whereas 8.69% had a probable diagnosis of depression.

Table 1.

Weighted Participant Characteristics of Women Veterans in the Health of Vietnam Era Veteran Women’s Study (HealthViEWS) according to Cognitive Function Status (Defined by Performance on TICS)

		Cognitive function status		p
	All participants^a (n = 4,077)	Possible cognitive impairment (TICS ≤ 29; n = 263)	Nonimpaired (TICS > 29; n = 3,814)
	Mean ± SE or % (95% CI)^b	Mean ± SE or % (95% CI)^b	Mean ± SE or % (95% CI)^b
Cognitive status (TICS)	34.44 ± 0.06	26.75 ± 0.16	35.04 ± 0.04	<0.01
Age (years)
Study enrollment age	67.62 ± 0.10	70.76 ± 0.53	67.38 ± 0.10	<0.01
Military enlistment age	21.71 ± 0.06	22.55 ± 0.26	21.65 ± 0.06	<0.01
Military separation age	30.04 ± 0.16	33.07 ± 0.75	29.80 ± 0.16	<0.01
Years of military service	8.33 ± 0.14	10.56 ± 0.61	8.16 ± 0.14	<0.01
Education (n = 49 missing)				<0.01
Less than Bachelor’s degree	33.80 (32.28–35.31)	47.06 (40.78–53.33)	32.76 (31.21–34.31)
Bachelor’s degree or higher	66.21 (64.69–67.72)	52.94 (46.67–59.22)	67.24 (65.69–68.79)
Race (n = 1 missing)				<0.01
Non-White	9.12 (8.13–10.11)	14.74 (10.03–19.45)	8.69 (7.69–9.69)
White	90.88 (89.89–91.87)	85.26 (80.55–89.97)	91.31 (90.31–92.31)
Ethnicity (n = 143 missing)				0.01
Spanish, Hispanic, or Latino	2.27 (1.78–2.76)	4.82 (2.06–7.58)	2.08 (1.60–2.57)
Not Spanish, Hispanic, or Latino	97.73 (97.24–98.22)	95.18 (92.42–97.94)	97.92 (97.43–98.40)
Marital status (n = 52 missing)				<0.01
Married or living with partner	48.94 (47.35–50.53)	36.10 (30.12–42.07)	49.94 (48.29–51.58)
Divorced, separated, or widowed	28.30 (26.86–29.74)	30.08 (24.40–35.76)	28.16 (26.67–29.64)
Never Married	22.77 (21.38–24.15)	33.82 (27.73–39.91)	21.90 (20.49–23.31)
Wartime service location				0.39
Elsewhere (near Vietnam or U.S.)	58.39 (56.86–59.92)	55.80 (49.65–61.96)	58.59 (57.01–60.17)
Vietnam	41.61 (40.08–43.14)	44.20 (38.04–50.35)	41.41 (39.83–42.99)
Job in military ^c (n = 6 missing)				<0.01
Other	32.15 (30.61–33.68)	44.83 (38.56–51.10)	31.16 (29.58–32.74)
Nurse	67.85 (66.32–69.39)	55.17 (48.90–61.44)	68.84 (67.26–70.42)
Probable PTSD diagnosis (CIDI)	11.77 (10.79–12.76)	12.34 (8.46–16.22)	11.73 (10.71–12.74)	0.76
Probable depression diagnosis (CIDI)	8.69 (7.82–9.56)	11.24 (7.48–15.01)	8.49 (7.60–9.39)	0.12
Self-reported PTSD symptom severity (PCL-C; n = 212 missing)	24.47 ± 0.17	27.69 ± 0.87	24.24 ± 0.17	<0.01
Self-reported depression symptom severity (PHQ9; n = 176 missing)	4.12 ± 0.08	5.71 ± 0.39	4.00 ± 0.08	<0.01

Bolded p values are statistically significant.

Participants were included in the analysis if they were ≥ 60 years old and had TICS data available.

Weighted percentages have been rounded to two decimal places and may not add to 100.

Nurse status identified from military service records.

CIDI, composite international diagnostic interview; PCL-C, PTSD checklist for DSM-IV-civilian version; PHQ-9, patient health questionnaire-9; PTSD, posttraumatic stress disorder; SD, standard deviation; TICS, telephone interview for cognitive status; CI, confidence interval.

Participants with possible cognitive impairment (versus nonimpaired) were older at study enrollment and at military enlistment/separation, as well as served longer in the military (p-value < 0.01 for all). In addition, a lower proportion of participants with possible cognitive impairment (versus nonimpaired) had a bachelor’s degree or higher (52.94% versus 67.24%), were White (85.26% versus 91.31%), were married or living with a partner (36.10% versus 49.94%), and served as a nurse in the military (55.17% versus 68.84%; p < 0.01 for all). Finally, participants with possible cognitive impairment (versus nonimpaired) self-reported greater PTSD and depression symptom severity (p < 0.01 for both).

Relationship between symptom severity and possible cognitive impairment

Table 2 depicts the weighted logistic regression analyses reported as ORs and 95% CIs for each self-reported symptom severity score. In the unadjusted and adjusted models for PTSD symptom severity, the odds of possible cognitive impairment were 1.03 times higher for every one-point increase on the PCL-C, which corresponds with an increase in PTSD symptom severity (95% CI: 1.02–1.04, p < 0.01). In the adjusted model, a one-year increase in age was associated with greater odds of possible cognitive impairment (aOR: 1.09, 95% CI: 1.06–1.12, p < 0.01), whereas higher education (Bachelor’s degree or higher compared to those with less education) was associated with lower odds of possible cognitive impairment (aOR: 0.47, 95% CI: 0.36–0.62, p < 0.01). In addition, White participants had lower odds of possible cognitive impairment compared with non-White participants (aOR: 0.58, 95% CI: 0.37–0.90). Marital status and wartime service location were not significant predictors of possible cognitive impairment.

Table 2.

Odds of Possible Cognitive Impairment by Self-Reported Posttraumatic Stress Disorder and Depression Symptom Severity

	Unadjusted model^a		Adjusted model^b
	OR (95% CI)	p	OR (95% CI)	p
Self-reported PTSD symptom severity (PCL-C; per 1 point increment)^c	1.03 (1.02–1.04)	<0.01	1.03 (1.02–1.04)	<0.01
Age (per 1 year increment)^d			1.09 (1.06–1.12)	<0.01
Education
Less than a Bachelor’s degree			1.00 (reference)
Bachelor’s degree or higher			0.47 (0.36–0.62)	<0.01
Race
Non-White			1.00 (reference)
White			0.58 (0.37–0.90)	0.01
Marital status
Married or living with partner			1.00 (reference)
Divorced, separated, or widowed			1.02 (0.72–1.44)	0.85
Never married			1.10 (0.74–1.62)	0.64
Wartime service location
Elsewhere (near Vietnam or U.S.)			1.00 (reference)
Vietnam			0.90 (0.68–1.19)	0.46
Self-reported depression symptom severity (PHQ-9; per 1 point increment)^c	1.06 (1.04–1.09)	<0.01	1.07 (1.04–1.09)	<0.01
Age (per 1 year increment)^d			1.09 (1.06–1.12)	<0.01
Education
Less than a Bachelor’s degree			1.00 (reference)
Bachelor’s degree or higher			0.52 (0.39–0.68)	<0.01
Race
Non-White			1.00 (reference)
White			0.56 (0.36–0.87)	0.01
Marital status
Married or living with partner			1.00 (reference)
Divorced, separated, or widowed			1.07 (0.76–1.50)	0.98
Never married			1.13 (0.78–1.66)	0.59
Wartime service location
Elsewhere (near Vietnam or US)			1.00 (reference)
Vietnam			0.97 (0.74–1.28)	0.82

Bolded p values are statistically significant.

Unadjusted model for PTSD symptom severity (n = 3,865); Unadjusted model for depression symptom severity (n = 3,901).

Adjusted models are adjusted for age, level of education, race, marital status, and wartime service location (PTSD symptom severity: n = 3,809; depression symptom severity: n = 3,845).

The self-reported PTSD and depression symptom severity were assessed as continuous variables in the statistical models.

Age: All participants were ≥ 60 years old.

CI, confidence interval; OR, odds ratio; PCL-C, PTSD checklist for DSM-IV-civilian version; PHQ-9, patient health questionnaire-9; PTSD, posttraumatic stress disorder; TICS, telephone interview for cognitive status. Cognitive function was based on performance on the TICS (≤29: possible cognitive impairment; >29: nonimpaired).

In the unadjusted model for depression symptom severity, the odds of possible cognitive impairment were 1.06 times higher for every one-point increase on the PHQ-9, which corresponds with an increase in depression symptom severity (95% CI: 1.04–1.09, p < 0.01). This association remained statistically significant even after controlling for age, level of education, race, marital status, and wartime service location (aOR: 1.07, 95% CI: 1.04–1.09, p < 0.01). Similar odds ratios previously reported for age, level of education, and race were found.

Relationship between probable diagnoses and possible cognitive impairment

Table 3 displays the weighted logistic regression analyses reported as ORs and 95% CIs for each probable diagnosis of PTSD and depression (CIDI). The relationship between probable PTSD diagnosis and possible cognitive impairment was not significant in both the unadjusted and adjusted models (p > 0.05). However, the relationship between probable depression diagnosis and possible cognitive impairment was statistically significant only after adjusting for age, level of education, race, marital status, and wartime service location (p = 0.02). Specifically, the odds of possible cognitive impairment were 1.61 times higher for those with a probable diagnosis of depression compared with those without depression (95% CI: 1.07–2.42, p = 0.02).

Table 3.

Odds of Possible Cognitive Impairment (95% Confidence Intervals) by Probable Diagnosis of Posttraumatic Stress Disorder and Depression (CIDI)

	Unadjusted model^a		Adjusted model^b
	OR (95% CI)	p	OR (95% CI)	p
Probable PTSD diagnosis (CIDI)^c
No PTSD	1.00 (reference)		1.00 (reference)
PTSD	1.06 (0.73–1.54)	0.76	1.31 (0.89–1.92)	0.17
Age (per 1 year increment)^d			1.09 (1.06–1.11)	<0.01
Education
Less than a Bachelor’s degree			1.00 (reference)
Bachelor’s degree or higher			0.49 (0.37–0.63)	<0.01
Race
Non-White			1.00 (reference)
White			0.55 (0.36–0.85)	0.01
Marital status
Married or living with partner			1.00 (reference)
Divorced, separated, or widowed			1.16 (0.84–1.61)	0.76
Never married			1.23 (0.85–1.78)	0.42
Wartime service location
Elsewhere (near Vietnam or US)			1.00 (reference)
Vietnam			1.01 (0.77–1.31)	0.95
Probable depression diagnosis (CIDI)^c
No depression	1.00 (reference)		1.00 (reference)
Depression	1.37 (0.92–2.03)	0.12	1.61 (1.07–2.42)	0.02
Age (per 1 year increment)^d			1.09 (1.06–1.12)	<0.01
Education
Less than a Bachelor’s degree			1.00 (reference)
Bachelor’s degree or higher			0.49 (0.38–0.64)	<0.01
Race
Non-White			1.00 (reference)
White			0.57 (0.37–0.87)	0.01
Marital status
Married or living with partner			1.00 (reference)
Divorced, separated, or widowed			1.14 (0.82–1.58)	0.82
Never married			1.21 (0.84–1.75)	0.44
Wartime service location
Elsewhere (near Vietnam or US)			1.00 (reference)
Vietnam			1.01 (0.78–1.31)	0.94

Bolded p values are statistically significant.

Unadjusted models contained the full sample (n = 4,077).

Adjusted models are adjusted for age, level of education, race, marital status, and wartime service location (n = 4,014).

CIDI probable diagnoses of PTSD and depression were treated as dichotomous variables (yes/no) in each statistical model.

Age: All participants were ≥ 60 years old.

CI, confidence interval; CIDI, composite international diagnostic interview; OR, odds ratio; PTSD, posttraumatic stress disorder; TICS, telephone interview for cognitive status. Cognitive function was based on performance on the TICS (≤29: possible cognitive impairment; >29: nonimpaired).

Discussion

This analysis examined the extent to which self-reported PTSD and depression symptom severity and interviewer-rated diagnoses of PTSD and depression were associated with late-life cognitive function in an understudied population of older women veterans. Our results demonstrated that self-reported PTSD and depression symptoms were associated with possible cognitive impairment in that for every one-point increase in symptom severity scores, there was an incremental increase in the odds of possible cognitive impairment. In addition, women veterans with a probable diagnosis of depression had higher odds of possible cognitive impairment compared to those without depression; in contrast, no association was found for probable PTSD diagnosis. Age, level of education, and race were also significantly associated with possible cognitive impairment. These findings are important, given how little is known about women veterans’ health in general and mental health and cognition more specifically.

The observed associations between possible cognitive impairment and current mental health status in Vietnam-era women veterans are consistent with prior findings, predominantly studied in male populations.^{8,12,20,57,58} Furthermore, one large-scale epidemiological study demonstrated this link in a sample of older women veterans receiving care at VA medical centers, showing that a history of PTSD or depression, each independently, increased the likelihood of developing dementia compared to no history of either.³⁵ In contrast, our sample was not limited to women receiving care through the Veterans Health Administration system. Therefore, this analysis expands on the evidence base in a meaningful way using a telephone-based screening measure and both self-reported symptom severity and probable diagnoses of PTSD and depression to demonstrate associations between cognitive functioning and mental health status.

Self-reported symptoms of psychological distress were consistently associated with possible cognitive impairment in this analysis, but this was not the case for both CIDI probable diagnoses. Specifically, a probable depression diagnosis was associated with possible cognitive impairment, whereas no association was found for a probable diagnosis of PTSD. There is a large body of literature outlining consistent associations between depression and cognitive impairment.^7,59,60 The influence of PTSD on cognitive impairment is more variable than the patterns associated with depression,^61,62 which may be due to the heterogeneity in the PTSD measures and neuropsychological instruments administered within and across studies.^8,62 PTSD has been associated with deficits in individual cognitive domains.^8,62,63 However, comparability of our findings with studies examining individual cognitive domains is limited, given that the TICS is a screening measure of global cognitive functioning and does not assess every domain, including visual memory or verbal delayed recall (an aspect of memory that reflects retrieval difficulties).⁶⁴ Further examination outlining differences between global measures of cognition and individual cognitive domains and associations with PTSD is necessary, as the neurocognitive profile associated with trauma-related anxiety is less understood.

Although the PCL-C checklist has favorable psychometric properties and is comparable to the CIDI PTSD module when using optimal cutoffs,^65,66 differences were observed in the findings between self-reported PTSD symptom severity and probable PTSD diagnosis. Previous civilian-based studies demonstrated an association between the number of self-reported PTSD symptoms and deficits in individual domains (e.g., psychomotor speed/attention and learning/working memory) in women.^67,68 In an examination of individuals 65 years and older, Nilaweera et al.⁶⁹ found that women with a history of trauma who self-reported re-experiencing PTSD symptoms had greater odds of lower global cognition compared to women with no trauma history. There are few studies examining the association between PTSD diagnosis and global cognition, with one study observing worse global cognitive function in Holocaust survivors with comorbid schizophrenia and PTSD compared with patients with schizophrenia who did not experience the Holocaust.⁷⁰ As such, this evidence outlines the necessity of assessing both global and domain-specific cognition and associations with PTSD and depression, particularly in examining late-life cognition among women.

In this sample of Vietnam-era women veterans, there was a low proportion of women with possible cognitive impairment. One longitudinal study identified an association between veteran status and initial protective factors that influence greater cognitive reserve.⁷¹ These protective factors include higher education levels, engagement in cognitive activity, and occupational attainment.^71
–73 Age was consistently associated with greater odds of possible cognitive impairment across all current results. This aligns with findings that women veterans have more pronounced cognitive changes compared with nonveterans after a certain age,⁷¹ suggesting that some factors may be protective up to a certain point. However, when assessed later, cognitive changes may increase, particularly for those with greater cardiovascular disease burden.⁷¹ Thus, these findings demonstrate the importance of early detection of risk factors linked with cognitive impairment in women veterans to facilitate implementation of preventative measures and reduce rates of cognitive changes over time. The methods used in the HealthViEWS study further highlight the potential for identifying other health factors that can be screened over the phone. This is particularly important in situations where veterans have limited access to care and/or have competing demands that require the prioritization of other obligations (e.g., family responsibilities, career roles), which makes telephone-based assessment a viable solution, especially among women veterans.^74
–76

Findings from this analysis suggest several important directions for future work. The temporal sequencing is often unclear in the literature, as there are methodological challenges in determining whether cognitive deficits developed as a consequence of PTSD or depression, existed prior to the onset of these mental health disorders, or are secondary to the normal cognitive aging process (or other psychiatric comorbidity).^9,62 Therefore, the connections between psychological health and cognitive impairment in women veterans should be studied prospectively³⁵ to more firmly establish whether PTSD and depression represent risk factors for cognitive impairment (or vice versa) in women veterans. In addition, more comprehensive neuropsychological testing of smaller groups of Vietnam-era women could help better characterize cognitive impairment in this population and establish base rates of mild and major neurocognitive disorders (i.e., mild cognitive impairment and dementia), as well as etiological factors for these conditions. Furthermore, previous studies suggest that while the TICS has high diagnostic accuracy for dementia, this measure may be suboptimal for instances that require high specificity (e.g., reliably detecting symptoms suggestive of mild cognitive impairment versus nonimpaired cognition).^56,77 Thus, clinical interpretation of “ambiguous” categories when using cutoffs on the TICS may necessitate re-evaluation. Another direction would be to explore medical (e.g., cardiovascular disease, history of traumatic brain injury) and lifestyle factors (e.g., exercise, sleep, substance use) that could impact cognitive changes.⁷¹ Finally, continuing to examine the emotional and cognitive health of aging Vietnam-era women veterans may help lay the groundwork for understanding and improving the health trajectories of women veterans from the larger Iraq and Afghanistan cohorts, as base rates of dementia vary with setting and demographic characteristics.⁷⁸

There are several limitations to consider including how this analysis was cross-sectional and, therefore, causality cannot be established. The TICS, being a brief screening measure, has reduced sensitivity and specificity compared to a comprehensive neuropsychological battery. Relatedly, it was not possible to compare TICS performance with clinical diagnoses of mild or major neurocognitive disorder made via face-to-face examinations, and validity measures were not assessed. Given that the TICS is telephone based, behavioral observations were not included (i.e., ensure an optimal testing environment, consider distractions or whether participants wrote things down, and so on). Administration and timing of measures should also be considered as interviewer-rated measures were administrated by trained lay interviewers after the initial mail survey was completed by participants. While reliable determination of TICS cutoff thresholds requires further evaluation, it is possible that using a threshold of ≤29 may have underestimated the rates of possible cognitive impairment in this sample of Vietnam-era women veterans. In addition, nonrespondents, including those who may have been too sick to respond (e.g., with cognitive impairment) or unwilling to participate, were not included which may have resulted in a lower percentage of women veterans with cognitive impairment in this analytic sample. Another limitation was the lack of information available on medical conditions (e.g., metabolic and cardiovascular diseases, history of traumatic brain injury). Lifestyle factors such as substance use were also not included as covariates; mainly because there were very few women with probable diagnoses of alcohol and drug abuse within a 12-month period (n = 32; n = 2, respectively).

Conclusion

Self-reported PTSD and depression symptom severity, as well as probable depression diagnosis, were each significantly associated with greater odds of possible cognitive impairment in this population. Although we cannot firmly conclude a causal relationship between PTSD/depression and cognitive impairment, the observed association suggests that older women veterans with PTSD or depression should potentially be prioritized for screening for cognitive difficulties. Identification of those with cognitive difficulties would allow for enrollment in one of the cognitive rehabilitation programs offered within the VA, including Brain Boosters and Cognitive Symptom Management and Rehabilitation Therapy, which have been implemented for individuals with cognitive impairment and overlapping psychiatric symptoms, including PTSD.^79,80 Future studies should continue to explore mental health and late-life cognitive changes in older women veterans prospectively, work toward identifying causal factors for cognitive disorders, and include women veterans from later eras as this population continues to grow.

Footnotes

Acknowledgment

This research was supported by the United States Department of Veterans Affairs, Veterans Health Administration, VA Office of Research and Development, Cooperative Studies Program (CSP #579).

Authors’ Contributions

C.B.B. conceptualization, methodology, formal analysis, writing—original draft & editing, and visualization; M.M.V. conceptualization and writing—original draft & editing; L.M.S. conceptualization and writing—original draft; Y.C. writing—reviewing & editing and supervision; A.S. writing—reviewing & editing and supervision; S.M.F. writing—review & editing and supervision; K.M.M. writing—reviewing & editing and funding acquisition; A.M.K. writing—reviewing & editing and funding acquisition; R.K. writing—reviewing & editing; M.J.R. writing—reviewing & editing and supervision.

Author Disclosure Statement

The authors declare that there are no conflicts of interest. The opinions presented in this article are those of the authors and do not reflect the views of any institution/agency of the U.S. government or the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.

Funding Information

No funding was received for writing this article.

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Mental Health and Cognition in Women Veterans Enrolled in the Health of Vietnam Era Veteran Women’s Study (HealthViEWS)

Abstract

Objective:

Methods:

Results:

Conclusions:

Introduction

Materials and Methods

Study participants

Procedures

Measures

Self-reported measures

PTSD checklist for DSM-IV-Civilian version 42

Patient health questionnaire-9 43

Demographics

Telephone-administered measures

Composite international diagnostic interview version 3.0 48

Telephone interview for cognitive status 51

Statistical analyses

Results

Demographic characteristics

Relationship between symptom severity and possible cognitive impairment

Relationship between probable diagnoses and possible cognitive impairment

Discussion

Conclusion

Footnotes

Acknowledgment

Authors’ Contributions

Author Disclosure Statement

Funding Information

References

PTSD checklist for DSM-IV-Civilian version⁴²

Patient health questionnaire-9⁴³

Composite international diagnostic interview version 3.0⁴⁸

Telephone interview for cognitive status⁵¹