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Invited Commentary
February 5, 2020

Repeated Assessment of Posttraumatic Stress Disorder Severity and the Risk of Mortality

Author Affiliations
  • 1Department of Family and Community Medicine, St Louis University School of Medicine, St Louis, Missouri
  • 2Harry S. Truman Veterans Administration Medical Center, Columbia, Missouri
  • 3National Center for PTSD and Department of Psychiatry, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
JAMA Netw Open. 2020;3(2):e1920493. doi:10.1001/jamanetworkopen.2019.20493

Strong evidence supports the conclusion that posttraumatic stress disorder (PTSD) is associated with increased risk of numerous adverse health outcomes. As described by Schnurr and Green, poor health and higher mortality rates among those with PTSD may be because of the “downward spiral that follows the wear and tear caused by PTSD.”1 Existing studies of PTSD and mortality have typically assessed mortality many years after a single baseline PTSD measurment.2 This approach does not account for the potential difference in mortality risk among those who have severe, persistent PTSD compared with those who experience remission or those who have a variable pattern of improving and worsening symptoms. Giesinger et al3 performed a large prospective cohort study from the World Trade Center (WTC) Health Registry, using 4 waves of data collection from more than 63 000 civilians and first responders who were exposed to the WTC disaster. Investigators used PTSD Checklist (PCL) scores of 50 or greater to define PTSD and identified mortality through National Death Index data. Among all participants, 2349 deaths occurred during the 13-year follow-up period, including 487 with cardiovascular mortality and 230 with an external cause of death (including suicide and accidental poisoning). The study by Giesinger et al3 was unique in that it compared the magnitude of the association between PTSD and mortality using 2 separate survival modeling approaches. First, PTSD was modeled as present or absent at baseline, and second, PTSD was treated as a time-varying exposure. When PTSD was modeled as present or absent at baseline, the magnitude of the association between PTSD and mortality was smaller and not statistically significant among civilians. When modeled as a time-varying exposure, PTSD was significantly associated with mortality among both civilians and first responders for all-cause, cardiovascular, and external-cause mortality.

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