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Cohen BE, Marmar C, Ren L, Bertenthal D, Seal KH. Association of Cardiovascular Risk Factors With Mental Health Diagnoses in Iraq and Afghanistan War Veterans Using VA Health Care. JAMA. 2009;302(5):489–492. doi:10.1001/jama.2009.1084
To the Editor: Studies of veterans from prior wars have found that those with posttraumatic stress disorder (PTSD) are at significantly increased risk of developing and dying from cardiovascular disease.1-3 To our knowledge, cardiovascular disease risk has not been evaluated in veterans from the current conflicts in Iraq and Afghanistan. We examined the association of PTSD and other mental disorders with cardiovascular risk factors using national data from veterans of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) who sought care at Department of Veterans Affairs (VA) facilities.
The data source was the VA OEF/OIF Roster, containing demographic and military service information on the 41% of eligible OEF/OIF veterans who have accessed VA health care. The study population consisted of 303 223 veterans who were new users of VA health care from October 7, 2001 (the start of OEF), to September 30, 2008. Data were linked to inpatient and outpatient VA electronic health care records. Codes from the International Classification of Diseases, Ninth Revision (ICD-9) were used to categorize veterans into those with (1) no mental health diagnoses, (2) mental health diagnoses excluding PTSD, and (3) PTSD with or without comorbid mental health diagnoses. Outcomes were ICD-9 codes for cardiovascular risk factors, including tobacco use, hypertension, hyperlipidemia, obesity, and diabetes mellitus.
We used sex-stratified, multivariable logistic regression models to examine the association between mental health diagnoses and cardiovascular risk factors (using a separate model for each cardiovascular risk factor), adjusted for age, race, military component (active duty vs National Guard/Reserve), rank, branch, and whether a veteran had multiple deployments. Race was included because of racial variation in mental health diagnoses and cardiac risk factor prevalence and was categorized by patient self-report. Veterans with mental disorders have higher use of medical services (such as primary care), which could lead to ascertainment bias if these veterans had more frequent assessment of cardiovascular risk factors.4-6 Therefore, we conducted a sensitivity analysis with additional adjustment for each veteran's number of primary care and medical subspecialty visits.
All tests were 2-tailed with α = .05 and performed using SAS version 9.1 (SAS Institute Inc, Cary, North Carolina). Estimated study power was 80% to detect odds ratios of 1.1 to 1.4 in men (depending on the cardiac risk factor) and 1.4 to 1.6 (except 3.0 for diabetes) in women. The use of deidentified administrative data met criteria for exemption from consent; the study was approved by the institutional review boards of the San Francisco VA and the University of California, San Francisco.
The mean (SD) age of the study population was 31 (9) years and 88% were men. The most common mental health diagnosis was PTSD (24% prevalence). The majority of patients with PTSD had comorbid mental health diagnoses, including depression (53%), anxiety disorder (29%), adjustment disorder (26%), alcohol use disorder (22%), substance use disorder (10%), and other psychiatric diagnoses (33%).
Veterans with mental health diagnoses had a significantly higher prevalence of all cardiovascular risk factors (Table 1 and Table 2). Adjustment for demographic and military factors changed these associations minimally. Further adjustment for primary care and subspecialty visits reduced effect sizes, but associations between mental health diagnoses and cardiovascular risk factors remained significant except for some associations with diabetes.
After adjustment for several potential confounding factors, male and female OEF/OIF veterans with mental health diagnoses had significantly greater rates of tobacco use, hypertension, hyperlipidemia, and obesity than those without mental health diagnoses. Study limitations include potential lack of generalizability to non-VA enrolled veterans; possible misclassification, underdiagnosis, or overdiagnosis of mental disorders or cardiovascular risk factors due to reliance on ICD-9 codes; and inability to determine causality due to the cross-sectional design. Despite these limitations, this study highlights the need for prospective studies to further investigate the association of specific mental health disorders with cardiovascular risk factors and the possible development of cardiovascular disease as these younger veterans age.
Author Contributions: Dr Seal had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Cohen, Bertenthal, Seal.
Acquisition of data: Bertenthal, Seal.
Analysis and interpretation of data: Cohen, Marmar, Ren, Bertenthal, Seal.
Drafting of the manuscript: Cohen.
Critical revision of the manuscript for important intellectual content: Cohen, Marmar, Ren, Bertenthal, Seal.
Statistical analysis: Ren.
Obtaining funding: Cohen, Seal.
Administrative, technical, or material support: Seal.
Study supervision: Marmar, Bertenthal, Seal.
Financial Disclosure: None reported.
Funding/Support: This study was funded by a VA Research Fellowship (Dr Seal), a VA Health Services Research and Development (HSR&D) Career Development Transition Award (Dr Seal), and a grant from the VA Seattle Epidemiological Research and Information Center (Dr Seal). Dr Cohen was supported by NIH/NCRR/OD UCSF-CTSI grant KL2 RR024130. This material is based on work supported in part by the VA HSR&D Research Enhancement Award Program, San Francisco VA Medical Center (REA 01-097).
Role of the Sponsor: The funding sources had no role in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.