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Original Investigation
August 21, 2019

Association Between Clinically Meaningful Posttraumatic Stress Disorder Improvement and Risk of Type 2 Diabetes

Author Affiliations
  • 1Department of Family and Community Medicine, Saint Louis University School of Medicine, St Louis, Missouri
  • 2Harry S. Truman Veterans Administration Medical Center, Columbia, Missouri
  • 3National Center for PTSD, Veterans Affairs (VA) Center of Excellence for Stress and Mental Health, Department of Psychiatry, University of California, San Diego
  • 4National Center for PTSD, Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
  • 5Trauma Recovery Center, Cincinnati Veterans Affairs Medical Center (VAMC), Cincinnati, Ohio
  • 6Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio
  • 7Sheila C. Johnson Center for Clinical Services, Department of Human Services, University of Virginia, Charlottesville
  • 8Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas
  • 9School of Medicine, Department of Medicine, University of California, San Francisco
  • 10San Francisco VAMC, San Francisco, California
  • 11Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
  • 12The Bell Street Clinic Opioid Treatment Program, Mental Health Service, VA St Louis Health Care System, St Louis, Missouri
JAMA Psychiatry. Published online August 21, 2019. doi:10.1001/jamapsychiatry.2019.2096
Key Points

Question  Is clinically meaningful posttraumatic stress disorder symptom decrease (≥20-point decrease on the Posttraumatic Stress Disorder Checklist score) associated with a lower risk of incident type 2 diabetes compared with less than a clinically meaningful or no improvement?

Findings  In this cohort study of medical records from 1598 patients, clinically meaningful posttraumatic stress disorder improvement compared with less than clinically meaningful or no improvement was associated with a 49% lower risk of incident type 2 diabetes.

Meaning  Long-term chronic health conditions associated with posttraumatic stress disorder may be less likely to occur among patients who experience clinically meaningful symptom reduction through treatment or spontaneous improvement.


Importance  Posttraumatic stress disorder (PTSD) is associated with increased risk of type 2 diabetes (T2D). Improvement in PTSD has been associated with improved self-reported physical health and hypertension; however, there is no literature, to our knowledge, on whether PTSD improvement is associated with T2D risk.

Objective  To examine whether clinically meaningful PTSD symptom reduction is associated with lower risk of T2D.

Design, Setting, and Participants  This retrospective cohort study examined Veterans Health Affairs medical record data from 5916 patients who received PTSD specialty care between fiscal years 2008 and 2012 and were followed up through fiscal year 2015. Eligible patients had 1 or more PTSD Checklist (PCL) scores of 50 or higher between fiscal years 2008 and 2012 and a second PCL score within the following 12 months and at least 8 weeks after the first PCL score of 50 or higher. The index date was 12 months after the first PCL score. Patients were free of T2D diagnosis or an antidiabetic medication use for 12 months before the index date and had at least 1 visit after the index date. Data analyses were completed during January 2019.

Exposures  Reduction in PCL scores during a 12-month period was used to define patients as those with a clinically meaningful improvement (≥20-point PCL score decrease) and patients with less or no improvement (<20-point PCL score decrease).

Main Outcomes and Measures  Incident T2D diagnosed during a 2- to 6-year follow-up.

Results  Medical records from a total of 1598 patients (mean [SD] age, 42.1 [13.4] years; 1347 [84.3%] male; 1060 [66.3%] white) were studied. The age-adjusted cumulative incidence of T2D was 2.6% among patients with a clinically meaningful PCL score decrease and 5.9% among patients without a clinically meaningful PCL score decrease (P = .003). After control for confounding, patients with a clinically meaningful PCL score decrease were significantly less likely to develop T2DM compared with those without a clinically meaningful decrease (hazard ratio, 0.51; 95% CI, 0.26-0.98).

Conclusions and Relevance  The findings suggest that clinically meaningful reductions in PTSD symptoms are associated with a lower risk of T2D. A decrease in PCL score, whether through treatment or spontaneous improvement, may help mitigate the greater risk of T2D in patients with PTSD.

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    2 Comments for this article
    Low Testosterone may be Causative in PTSD and T2D
    James Howard, BS | Independent Biologist
    I suggest the basis of the findings of Scherrer, et al., is an increase in testosterone. The medical literature supports a connection of PTSD and T2D with low testosterone. Increases in testosterone could affect both.
    Another way to look at this data.
    Gurpreet Padda, MD | Anesthesiology, Interventional Pain, Addiction
    Could the improvements in metainflammation resulting in reduced risk of T2DM progression be associated with the regression of PTSD symptoms, instead of the successful treatment of PTSD resulting in reduced T2DM?

    The relevance is that T2DM is predominantly a lifestyle mediated metabolic dysfunction. Preventing progression of excessive glycation by changes in lifestyle likely impacts comorbid PTSD symptoms.

    In my clinical experience, as metainflammation is reduced, so is depression, anxiety, pain, and PTSD symptoms independently of any pharmaceutical intervention. Most patient's wean from anxiolytics, antidepressants and opiate analgesics as their metainflammation improves.

    Lifestyle changes which improve
    gut permeability and vagal tone (part of the interaction between the Central Nervous System and the Enteric Nervous System) are likely a significant contributor to the hyper vigilance seen in PTSD patients.