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To determine if post-traumatic stress disorder (PTSD) is associated with health risk behaviors among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans attending college.
Using 2008 Boynton College Student Health Survey data, we tested associations between self-reported PTSD diagnosis and self-reported risk behaviors (n = 406).
We found PTSD diagnosis to be significantly associated with reporting involvement in a physical fight in the past year (ARR = 3.1; 95% CI: 2.2, 4.4) and marginally associated with high risk drinking (ARR = 1.3; 95% CI: 1.1, 1.6). However, no association was seen between PTSD and the tobacco use and other safety behaviors that we examined.
PTSD is likely a factor that contributes to the relationship between military service and certain health risk behaviors.
In the Fall of 2009, experts anticipated that 460,000 US military veterans of the conflicts in Afghanistan and Iraq (Operation Enduring Freedom/Operation Iraqi Freedom – OEF/OIF) would attend postsecondary educational institutions on the GI Bill.1,2 With the post-9/11 GI Bill, which was introduced in 2009,3 there will likely be even more OEF/OIF veterans attending college in coming years. The college years are known to be a time when a variety of health risk behaviors are common in the general student population.4 Our past research, which used data collected from veterans who were attending college in 2008, has shown a correlation between being a student who is an OEF/OIF veteran and being at increased risk for tobacco use, alcohol misuse, and unsafe behaviors compared to non-veteran students.5 The reasons for these risks likely relate to a complex array of factors that include combat exposure, reintegration challenges, and emotional/mental health issues.
Post-traumatic stress disorder (PTSD), which is an anxiety disorder that can result from exposure to physically harmful situations, is one of the most frequently occurring mental health problems among OEF/OIF veterans.6 The prevelance of a lifetime history of PTSD has been reported to be from 4–8% in general college student populations.7 While research has consistently found an association between history of trauma and substance use among college students,7 the association between PTSD and alcohol use and other risky health behaviors among college students has received little attention.7,8
Studies of earlier generations of veterans have provided strong evidence for PTSD being related to a variety of high-risk health behaviors, including substance use and weight-related behaviors.9 There is growing evidence for a relationship between PTSD and health risk behaviors among OEF/OIF veterans. In an analysis of a sample that included all OEF/OIF veterans who have accessed VA healthcare services, those with PTSD were more likely to use tobacco.10 Indeed, the etiology of the high rates of tobacco use in the OEF/OIF population may be partially related to PTSD as there is evidence for a bi-directional causal relationship between PTSD and tobacco use.11–13 In the area of alcohol and substance use, the youngest OEF/OIF veterans (< age 25) are a population of concern as their rates of PTSD have been shown to be higher than older OEF/OIF veterans (> age 40) and they experience higher rates of alcohol and drug use disorders14 which may be either a consequence of and/or causal factor in PTSD. In the Millennium Cohort Study, those with PTSD symptoms at baseline were at increased risk for alcohol problems at follow-up.15 It is also known that veterans who have been exposed to violent combat are more likely to engage in aggressive behaviors upon returning home.16 OEF/OIF veterans diagnosed with PTSD or Traumatic Brain Injury (TBI) are known to be at increased risk for behaviors that compromise their safety.17
The aim of this study was to specifically test associations between self-reported PTSD diagnosis and several select health risk behaviors in a population of OEF/OIF veterans attending postsecondary educational institutions. We hypothesized that the increased occurrence of PTSD in the OEF/OIF population could relate to the higher prevalence of risk behaviors observed in OEF/OIF veteran students.
This is a secondary data analysis of the University of Minnesota’s Boynton Health Service’s College Student Health Survey (CSHS) which was designed to serve as a surveillance tool to monitor the health of Minnesota’s college students. The schools included in the CSHS are not chosen at random. Any post-secondary educational institution in Minnesota that wishes to gather surveillance data on the health behaviors are welcome to participate. A random sample of students at 14 public and private, 2- and 4-year colleges and universities in Minnesota was invited to complete the anonymous, web-based 2008 CSHS. Survey and recruitment procedures were identical at all schools. In addition, all students identified by their institutions as US military veterans at these 14 schools were invited to take part in the study; and to increase the veteran sample size, all veteran students from one additional university were identified and invited to participate. Of the 1,901 student veterans invited to participate, 42.8% completed the survey, 49.2% of whom reported serving in OEF/OIF. Thus, the veteran response rate was higher than the 2008 CSHS overall response which of 32.8%. The University of Minnesota Institutional Review Board approved all procedures for this study. Permission to conduct the research was also obtained at the institutions the subjects attended.
The CSHS included items covering a variety of issues germane to the health of college students (such as nutrition, physical activity, substance use, sexual health). The full survey is accessible online (http://www.bhs.umn.edu/healthdata/surveys/index.htm and click on “2008 College Student Health Survey Questionnaire”). Demographics including age, gender and race/ethnicity were ascertained. Veteran status was assessed by 2 items, “Are you currently or have you ever served in the United States Armed Forces?” and, “Are you an Operation Iraqi Freedom and/or Operation Enduring Freedom veteran?” with response options of ‘yes’ and ‘no’ for both questions. The primary exposure of interest for this analysis was PTSD diagnosis in the past 12 months. Participants were asked to report if they had been diagnosed with PTSD in their lifetime and if yes, whether the diagnosis had been in the past 12 months. We focused on past 12 month diagnosis as this was more likely to be related to the veterans’ service. No data were collected to assess what incidents the PTSD may be related to and whether or not it had been treated.
The health behaviors of interest, tobacco use, alcohol use and safety, were selected due to previous findings that they were associated with OEF/OIF status.5 Participants were asked to report the average number of cigarettes smoked on weekdays and weekend days and how often they used smokeless tobacco in the past year (did not use, once/year, 6 times/year once/month, more than once/month). Students responded to questions asking about the number of times they had consumed 5 or more alcoholic drinks in one sitting in the previous 2 weeks and whether they rode in a car with a driver who was impaired by alcohol in the past year. Participants also reported whether they had driven a car while under the influence of any substance, had been “in a physical fight,” or had ridden a motorcycle in the past year (yes, no).
Due to concerns of the validity of self-reported PTSD diagnosis we conducted a rough validity check in these data. We examined associations between PTSD and both perceived stress (“On a scale of 1 to 10, with 1 being not stressed and 10 being very stressed, how would you rate your average level of stress in the past 30 days?”) and perceived stress management (“On a scale of 1 to 10, with 1 being ineffective and 10 being effective, how would you rate your ability to manage stress in the past 30 days?”). Since PTSD is an anxiety disorder, individuals with this diagnosis should experience increased stress and decreased ability to manage stress. Participants were asked to rank their “average level of stress in the past 30 days” and “ability to manage your stress in the past 30 days” on a 1–10 scale. Student veterans of OEF/OIF who reported that they had been diagnosed with PTSD in the past year reported more stress, but not less effectiveness with managing their stress.
Using Poisson regression, we calculated adjusted relative risks (ARR) with 95% confidence intervals (95% CI) to estimate the relationship between self-reported past year PTSD diagnosis and health risk behaviors among veterans. Although logistic regression is often used to model relationships among predictors and dichotomous outcomes in public health research, we chose to use Poisson regression because odds ratios derived from logistic regression can overestimate associations when the outcome is not rare (when prevalence greater than approximately 10%).18 Unless otherwise noted in Table 1, prevalence ratios were adjusted for gender, year in school, age (continuous), and race/ethnicity (African American/Black, American Indian/Alaskan Native, Asian/Pacific Islander, Latino/Hispanic, Middle Eastern, White/Caucasian, Other). In order to address the potential correlation of outcomes within institutions, we computed confidence intervals using Huber-White (robust) standard errors.19 Analyses were conducted in STATA SE 10.0 (StataCorp, College Station, TX).
The majority (78%) of OEF/OIF veterans were male and slightly over half were older than age 25. Approximately 89% identified as “White/Caucasian.” Over 15% reported having been given a PTSD diagnosis at anytime in their lives and of those, 7.6% reported being diagnosed with PTSD in the past year.
Table 1 examines the associations between past year PTSD and select health risk behaviors in the OEF/OIF veteran sample. Past year PTSD diagnosis increased the risk of being involved in a physical fight (ARR = 3.11; 95% CI = 2.18, 4.44) and was associated with marginal significance to greater reporting of high-risk drinking (ARR = 1.32; 95% CI = 1.07, 1.64). No associations were observed between PTSD and the other health risk behaviors examined.
The high prevalence (15.5%) of self-reported lifetime or past year PTSD diagnosis among this sample of OEF/OIF veterans attending college is similar to other estimates in the OEF/OIF veteran population.6 Among these college veterans, we found past-year PTSD diagnosis to be associated with more than a 3-fold greater risk for fighting and a modest increased risk for high-risk drinking.
Our finding on fighting is consistent with a previous report of OEF/OIF veterans with PTSD being more likely to report aggression compared to OEF/OIF veterans with a PTSD diagnosis20 and a study showing that combat exposure among OIF veterans to be related to physical aggression towards others.16 The substantial increase in risk for fighting previously seen in OEF/OIF veterans attending college,5 may be in part due to PTSD related to their wartime combat exposure.
It was surprising that aside from fighting, PTSD was associated with minimal (in the case of high-risk drinking) to no increased risk of the other select health behaviors. An alternative explanation for the previously observed increased risk for these adverse behaviors among OEF/OIF veterans5 may be that they stem more from stress and adjustment difficulties related to combat deployments and subsequent reintegration than to PTSD. Another factor to consider is that PTSD is characterized by 3 clusters of symptoms and that measuring them together (by asking participants for self-report of PTSD diagnosis rather than specific symptoms) may mask some effects of individual symptoms on health risk behaviors. Recent research that has attempted to unpack the complex relationship between PTSD, alcohol, and aggression in Vietnam-era veterans has shown that of the 3 PTSD symptom clusters (hyperarousal, avoidance/numbing, and re-experiencing), only hyperarousal symptoms were positively associated with aggression (both directly and indirectly through alcohol problems).21 Perhaps veterans attending college who have PTSD are most likely to exhibit behaviors that result in aggression and impulsiveness.
Despite the weak association between PTSD and high-risk drinking, it is important to note that for young adult populations, alcohol use and abuse rates are generally very high. According to the 2008 National Survey on Drug Use and Health, both binge and heavy alcohol use is most common among 21–25 year olds and those young adults (age 18–22) enrolled in college full-time report more heavy drinking in the past month than those not in school.22 In a study by Knight and colleagues, 31% of students from a general college population met the DSM-IV criteria for alcohol abuse.23 Previously in the 2008 CSHS, after adjustment for age, gender, year in school, and race/ethnicity, we found that 48.3% OEF/OIF veteran college students in our study reported high-risk drinking compared to 29.8% in the non-veteran students.5
The lack of association between PTSD and the other risk behaviors among these OEF/OIF veterans may also be due to the relative recency of their deployment as most of the research demonstrating a connection between PTSD and risky behaviors has sampled veterans with chronic PTSD.9 It may be that soon after onset, PTSD does not confer unique risk in these areas, but over time, chronic PTSD begins to accentuate risky health behaviors. Thus, the ongoing relationship between PTSD and health risk behaviors in OEF/OIF veterans should be an area of future study.
Our study has several important limitations. First, all variables were based on self-report and therefore under- and/or over-reporting could be an issue with various items. With PTSD diagnosis, students (both veteran and non-veteran) may under-report because they feel uncomfortable sharing their diagnosis, are not aware of their diagnosis, have been misdiagnosed, or they may have PTSD but may not yet have had the opportunity to be assessed and diagnosed. We have some assurance from the fact that self-report of past year PTSD diagnosis was associated with self-report of higher past 30-day stress since PTSD is an anxiety disorder. However, we do not know whether those who report past year PTSD diagnosis have been or are currently in treatment and whether that treatment has been a success. Our study is also limited in its generalizability beyond the college setting. Veterans attending college are likely very different than those who are not. However, the study is strengthened by CSHS design which sampled students from a variety of types of postsecondary institutions which add diversity to the sample. We are somewhat limited by our sample size in the sense that real effects of PTSD on other health risk behaviors may have been too small for our study to detect. Finally, as is common in online survey research, the response rate of the CSHS was modest, but it was in the range of other studies on OEF/OIF veterans.4,24,25 It is unknown how responders differed from non-responders.
PTSD appears to be related to an elevated risk for several dangerous health behaviors in OEF/OIF veterans. Although health risk behaviors are prevalent among college-aged youth overall,4 our research suggests that OEF/OIF veterans attending college, and especially those who may have experienced trauma, may have special behavioral health needs. As the number of OEF/OIF veterans attending college increases, it will be crucial for college health service centers to be aware of the unique needs of students who are combat veterans in order to best promote the health of their college community.
This research was supported by Minnesota State Colleges and Universities System, the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, the Center for Chronic Disease Outcomes Research (CCDOR) a VA Health Services Research & Development (HSR&D) Center of Excellence, and the National Cancer Institute (NCI) Centers for Transdisciplinary Research on Energetics and Cancer (TREC) (U54CA116849). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
Rachel Widome, Center for Chronic Disease Outcomes Research (CCDOR), Assistant Professor, Department of Medicine, University of Minnesota, One Veterans Drive (152/2E), Minneapolis, MN 55417, Phone: (612) 629-7726, Fax: (612) 727-5699.
Shannon M Kehle, Center for Chronic Disease Outcomes Research (CCDOR), One Veterans Drive (152/2E), Minneapolis, MN 55417, Phone: (612) 467-1564, Fax: (612) 727-5699.
Kathleen F Carlson, Center for Chronic Disease Outcomes Research (CCDOR), Assistant Professor, Department of Medicine, University of Minnesota, One Veterans Drive (152/2E), Minneapolis, MN 55417, Phone: (612) 467-1421, Fax: (612) 727-5699.
Melissa Nelson Laska, Division of Epidemiology and Community Health, University of Minnesota, 1300 South 2nd St. #300, Minneapolis, MN 55454, Phone: (612) 624-8832, Fax: 612-624-0315.
Ashley Gulden, Center for Chronic Disease Outcomes Research (CCDOR), One Veterans Drive (152/2E), Minneapolis, MN 55417, Phone: (612) 467-4832, Fax: (612) 727-5699.
Katherine Lust, Boynton Health Service, University of Minnesota, 410 Church St S E, Minneapolis, MN 55455, Phone: 612-624-6214.