This study of female VA patients found that PTSD+ women were more likely than PTSD− women to be hospitalized for medical or surgical conditions. Moreover, outpatient utilization of ED, primary care, subspecialty care, ancillary services, and diagnostic testing was higher among PTSD+ women. The association between PTSD and utilization of health services was particularly strong in the 35- to 49-year-old age cohort, and the observed associations persisted after adjusting for other predictors of increased health care utilization (most notably age and smoking).
Trauma exposure, primarily sexual assault, is associated with negative physical and mental health outcomes in female veterans.9–13
Fewer studies have explored the association of PTSD with health outcomes in female VA patients; such studies have relied primarily on self-report.14, 25, 26, 32, 46
Our findings are consistent with previous studies and extend these findings by including a broadly selected sample of women seen for VA care, by using VA administrative records to evaluate the association of PTSD with VA health care utilization, and by prospectively following utilization for 2 to 5 years.
Findings from this study complement findings for male veterans.6, 20, 22, 24, 33, 47
Other investigators have used structural equation modeling to conclude that PTSD is an important mediator between trauma exposure and physical health in male veterans.28, 33, 35
While our analyses cannot address the presence of a causal association between PTSD and medical utilization, PTSD does appear to be associated with an increased use of inpatient and outpatient services in women seen for VA care.
Posttraumatic stress disorder is not unique among psychiatric conditions in its association with increased health care utilization. However, investigators have suggested that physical health problems may be particularly prominent in PTSD.21, 23, 25, 48, 49
The very high comorbidity between PTSD and depression observed in our sample make it difficult to analyze the effects of PTSD independent of depression. The use of a screening measure for depressive symptoms, the MHI-5, rather than a clinical diagnostic instrument further complicates our ability to precisely assess the impact of comorbid depression. Nonetheless, our secondary analyses suggest that screening positive for PTSD has an association with medical utilization at least comparable in strength to screening positive for depression. Lending support to this observation is a recent study of a national sample of female VA patients showing that women who endorsed coexisting PTSD and depression (representing 89% of the women with PTSD) reported a greater burden of medical illness than did those with depression alone.25
There are several possible explanations for the observed association between PTSD and health care utilization. Many investigators describe increased somatization in PTSD patients and attribute increased treatment utilization to subjective physical distress in these patients.24, 46, 50, 51
Comorbid conditions such as obesity, smoking, or substance abuse could also contribute to poorer health in individuals with PTSD.17, 39
Increased medical utilization may arise from injuries sustained during trauma, although little is known about this potential contribution. Other investigators have argued that the underlying neurobiology of PTSD may be associated with the early development of some medical conditions,52
a hypothesis consistent with longitudinal studies of health in male veterans with PTSD showing that their use of medical care at a younger age was not inappropriate.28, 35
A recent study of male veterans found a particularly robust association between VA primary care clinic visits and PTSD in men under the age of 52.31
Similarly, in our study, increased utilization was strongest among women ages 35 to 49; this age group may be particularly vulnerable to the negative impact of PTSD on physical health.
There are a number of limitations to this study. Participants were seen at one 2-site urban VA facility, suggesting caution before generalizing these findings to female veterans who are seen in other VA or non-VA facilities. However, our prior studies indicate that women in our sample are comparable with women seen elsewhere for VA care.39, 53
Although it is a validated screening instrument, the PCL-C is not a diagnostic interview for PTSD. Hence, our findings rely on a screening approximation of the actual prevalence of PTSD in this population. Another limitation is that we examined only VA services and so underestimated total health utilization, especially in nonservice-connected women (who were also less likely to have PTSD). We attempted to address this bias by incorporating service-connected disability into our regression models. Even after controlling for this and other potential confounding variables in our stepwise regression analyses, the impact of PTSD on utilization remained significant. Although our data do not capture community medical utilization, the results nonetheless illustrate a significant public health problem within the growing population of women served by VA. Finally, our data do not evaluate the appropriateness of the care received. Increased surgical utilization is of particular concern, given its related morbidity and costs. Although evidence suggests that VA provides high-quality care,54
the appropriateness of this care deserves further study.
In summary, symptoms of PTSD are common among women seen for care at VA facilities and are associated with higher medical/surgical utilization. Preliminary studies of Iraq War veterans suggest that, although stigma associated with mental illness discourages soldiers from seeking psychiatric care,55
the mental health consequences of the current conflict are substantial.56
Underutilization of VA mental health services may be particularly apparent in women.57
Thus, identification of PTSD in VA primary care settings is crucial, as specific and effective treatments for this condition are available.58
Future studies should focus on whether successful treatment of PTSD will result in a decrease in medical utilization. As more women serve in the military, the impact of PTSD on women's physical health presents an important consideration for the design of VA health services.