Posttraumatic Stress Disorder Screening Status is Associated with Increased VA Medical
and Surgical Utilization in Women
Dorcas J. Dobie, MD,1,2,3Charles Maynard, PhD,2,4,5Daniel R. Kivlahan, PhD,1,2,3,6
Kay M. Johnson, MD, MPH,2,7Tracy Simpson, PhD,2,3,8Andrew C. David,1,2,3
Katharine Bradley, MD, MPH2,4,7
1Mental Illness Research, Education and Clinical Center, University of Washington School of Medicine, Seattle, WA, USA;2Veterans Affairs
Puget Sound Health Care System, University of Washington School of Medicine, Seattle, WA, USA;3Departments of Psychiatry and
Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA;4Health Services Research and Development,
University of Washington School of Medicine, Seattle, WA, USA;5Epidemiology Research and Information Center, University of Washington
School of Medicine, Seattle, WA, USA;6Center of Excellence in Substance Abuse Treatment and Education, University of Washington
School of Medicine, Seattle, WA, USA;7Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA;
8Women’s Trauma Recovery Program, University of Washington School of Medicine, Seattle, WA, USA.
BACKGROUND: Women with posttraumatic stress dis-
order (PTSD) report poor health, but associations with
health care utilization are understudied.
OBJECTIVE: To determine associations between med-
ical/surgical utilization and PTSD in female Veterans
Affairs (VA) patients.
DESIGN: Prospective comparison of utilization rates
between women screening positive or negative for PTSD
on a mailed survey.
SUBJECTS: Women receiving care at an urban VA
medical center between October 1996and January2000.
MEASUREMENTS: Survey responses, including a val-
idated screen for PTSD (PCL-C), and VA utilization data
through September 2002.
RESULTS: Two thousand five hundred and seventy-
eight (2,578) women (78% of those eligible) completed
the PCL-C; 858 (33%) of them screened positive for
PTSD (PTSD1). In unadjusted models, PTSD1 women
had higher rates of medical/surgical hospitalizations
and surgical inpatient procedures. Among women ages
35 to 49, mean days hospitalized/100 patients/year
was 43.4 (95% CI 26 to 61) for PTSD1 women versus
17.0 (16 to 18) for PTSD negative (PTSD–) women. More
PTSD1 women underwentsurgical procedures (Po.001).
Mean annual outpatient visits were significantly higher
among PTSD1 women, including: emergency depart-
ment (ED) (1.1 [1.0 to 1.2] vs 0.6 [0.5 to 0.6]), primary
care (3.2 [3.0 to 3.4] vs 2.2 [2.1 to 2.3]), medical/surgical
subspecialists (2.1 [1.9 to 2.3] vs 1.5 [1.4 to 1.6]), ancil-
lary services (4.1 [3.7 to 4.5] vs 2.4 [2.2 to 2.6]), and di-
agnostic tests (5.6 [5.1 to 6.1] vs 3.7 [3.4 to 4.0]). In
multivariate models adjusted for demographics, smok-
ing, service access, and medical comorbidities, PTSD1
women had greater likelihood of medical/surgical hospi-
talization (OR=1.37 [1.04 to 1.79]) and of being among
the top quartile of patients for visits to the ED, primary
care, ancillary services, and diagnostic testing.
CONCLUSIONS: Female veterans who screen PTSD1
receive more VA medical/surgical services. Appropri-
ateness of that care deserves further study.
KEY WORDS: mental health; survey research; utiliza-
tion; veterans; women’s health.
J GEN INTERN MED 2006; 21:S58–64.
r 2006 by the Authors. No claim for US Government
health.1–6Female veterans have particularly high rates of life-
time exposure to such events7–15and are thereby susceptible
to potentially disabling sequelae such as posttraumatic stress
disorder (PTSD).16–18Posttraumatic stress disorder has been
associated with physical health problems19–27and increased
medical utilization.28–31Indeed, PTSD may independently
mediate some of the negative effects of trauma on physical
health.32–35Nonetheless, PTSD remains under-recognized in
both civilian and military health care settings.36–38
We recently completed a longitudinal health survey
among women seen for care in a large urban Veterans Affairs
(VA) health system. In cross-sectional analyses of year 1 sur-
veys, women who screened positive for PTSD had poorer self-
reported health status in both physical and mental domains
compared with women who screened negative.39In the present
study, we examined the association between PTSD and inpa-
tient and outpatient VA health care utilization among these
women. Specifically, we tested whether women who screened
positive for PTSD on a validated screening test had higher
rates of subsequent medical and/or surgical utilization than
women who screened negative for PTSD.
xposure to traumatic events such as physical assault,
sexual assault, combat, or severe injury has negative
consequences forbothphysical andmental
Female veterans who received care between October 1, 1996
and January 1, 2000 at VA Puget Sound Health Care System
The authors have no conflicts of interest to declare.
Address correspondence and requests for reprints to Dr. Dobie:
VAPSHCS (S-116), 1660 South Columbian Way, Seattle, WA 98108
(N=3,308) were mailed a Women’s Health Survey (WHS) an-
nually in 1998, 1999, and 2000. This report includes data
from 2,578 eligible women who returned at least 1 survey with
a completed screening test for PTSD. We only used data from
each woman’s first completed survey. Although detailed infor-
mation on nonrespondents was not available for this expanded
study population, previous analyses of the first year survey
showed that, compared with nonrespondents, respondents
were slightly older (M=47.4 vs 45.0), more likely to be white
(72% vs 66%), and more likely to have ever been married (81%
vs 77%).40The University of Washington Institutional Review
Board approved the study.
Survey Instrument. The WHS was 15 pages long in the first
year39,40and briefer in subsequent years. Each year, the sur-
vey included questions about demographic characteristics,
health behaviors, and mental health. The WHS also asked
about height, weight, and specific health problems including
hypertension, diabetes mellitus, stroke, hepatitis, thyroid dis-
ease, cancer, irritable bowel syndrome, and fibromyalgia.
PTSD. The PTSD Checklist-Civilian version (PCL-C) was used to
categorize patients based on PTSD symptoms.41Women with
PCL-C scores ?38 were considered ‘‘PTSD positive’’ (PTSD1);
scores o38 were considered ‘‘PTSD negative’’ (PTSD?). At this
threshold, the PCL-C has a 0.79 sensitivity and 0.79 specificity
for the DSM-IV diagnosis of PTSD based on the Clinician Ad-
ministered PTSD Schedule (CAPS) in this population.8
VA Health Care Utilization. Information about VA health care
utilization was obtained from the VA National Patient Care Da-
tabase (NPCD) from the first day of the year of study enrollment
through September 30, 2002. Duration of follow-up ranged
from over 5 years to a minimum of 2.7 years (M=3.9, SD=0.9).
For inpatient utilization, acute hospitalizations were cate-
gorized based on the bed section at discharge. Because these
analyses focused on medical/surgical utilization, we excluded
psychiatric hospitalizations, domiciliary, rehabilitation, spinal
cord injury, and nursing home stays from these analyses. Sur-
gical procedures that required inpatient stays and operating
room visits were categorized by ICD codes into cardiopulmo-
nary, gastrointestinal, genitourinary, musculoskeletal, or
Outpatient utilization was determined using VA ‘‘stop codes’’
that were grouped into 5 mutually exclusive categories (de-
tailed in legend Table 4): emergency department (ED), primary
care, medical/surgical subspecialty care, ancillary services, or
diagnostic tests. Outpatient mental health care and other clin-
ics with fewer than 100 visits during the study were excluded.
Death. Vital status was ascertained from the Beneficiary Iden-
tification Record Locator System (BIRLS) death file and the
NPCD. These data sources have high sensitivity for deaths of
Covariates. The WHS provided data on depression, alcohol
use disorders, smoking, and specific medical problems that
are commonly associated with PTSD.17,39Depression screen-
ing was performed using the 5-item Mental Health Index (MHI-
5).43Although it is not the most sensitive screen for alcohol
misuse in this population, the 5-item ‘‘TWEAK’’ question-
naire44was used to screen for active alcohol use disorders be-
cause of its high specificity (92%) and a positive likelihood ratio
of 5.1 (3.2 to 9.0).45Standard scoring algorithms and screen-
ing cutoffs were used for both the MHI-5 (?17) and TWEAK
(?2).43,45Body mass index (BMI) was calculated from self-re-
ported height and weight, with obesity defined as BMI?30.
Disability associated with military service was obtained from
the NPCD and categorized as ?50% disabled, o50% disabled,
or not disabled. Veterans with ?50% service-connected disa-
bility receive highest priority for access to VA care.
Descriptive analyses compared baseline characteristics and
mortality between PTSD1 and PTSD? women, using the w2
statistic for categorical variables and the 2-sample t-test for
continuous measures. Because of their infrequency, inpatient
surgical procedures were dichotomized as present or absent
during follow-up and were compared among PTSD1 and
PTSD? women by w2. For other bivariate analyses of the asso-
ciation between PTSD and healthcare utilization, utilization was
adjusted to take into account the varied follow-up from time of
the survey through September 2002. For hospitalizations, utili-
zation rates were constructed as days hospitalized per person
per year of follow-up. For outpatient care, the number of visits
per patient per year of follow-up were calculated. Given the non-
normal distribution of these inpatient and outpatient utilization
rates, differences in the 2 groups were assessed with the non-
parametric Wilcoxon’s rank sum test. Bivariate analyses were
stratified by age group (o35, 35 to 49, and ?50 years) based
on the expected increase in utilization with increasing age.
Multivariate logistic regression was used to evaluate
whether adjustment for potential confounding variables al-
tered the observed bivariate associations between PTSD and
health care utilization. For inpatient services, logistic regres-
sion was used to model the odds of any acute medical/surgical
inpatient hospitalization during the follow-up period. For out-
patient services, women were ranked based on their average
number of visits per year for each type of outpatient care (ED,
etc.). Women in the highest quartile were considered to have
‘‘high utilization.’’ High utilization was used as the outcome
variable for logistic regression analyses of the association be-
tween PTSD and each type of outpatient utilization. This ap-
proach to multivariate modeling was chosen because of the
nonnormal distribution of the outcome (days hospitalized/100
patients per year), the comparable years of follow-up for
PTSD1 and PTSD? women, and unavailability of dates of
hospitalizations that precluded modeling the time to event
(e.g., Cox proportional hazards models).
Logistic regression analyses were conducted using a
stepped approach to modeling: (1) unadjusted association be-
tween PTSD screening (1/?) and each subtype of utilization,
(2) adjusting for age and smoking, (3) separate full models for
each type of utilization (any medical/surgical hospitalization
and the categories of outpatient care: ED, primary care, med-
ical/surgical subspecialty, ancillary services, and diagnostic
testing). In these full models, the remaining covariates were
allowed to enter the model in a stepwise fashion with Po.05 as
the criterion for entry. Potential confounders were selected
because of association with increased medical utilization or
previously demonstrated association with PTSD in this popu-
lation.39Potential confounders included race, marital status,
education, service-connected disability ?50%, obesity, active
Dobie et al., PTSD and Medical Utilization in Women
alcohol use disorder, hypertension, diabetes mellitus, stroke,
thyroid disease, cancer, irritable bowel syndrome, and fib-
romyalgia. After adjusting for these other covariates, PTSD
status was entered at the last step to test its association with
Depression was not included in the above multivariate
models because of its extremely strong association with
PTSD1 in this sample (correlation MHI-5 score and PCL-C
score=0.78). However, secondary analyses compared the
strength of the association between PTSD and health care uti-
lization to that between depression and health care utilization.
To do this, the final regression model was replicated, substi-
tuting depression status based on the MHI-5 (screen positive
or negative) for PTSD screening status.
A total of 2,578 women (78% of those eligible) completed the
PCL-C on at least 1 survey and are included in these analyses.
The mean duration of follow-up was not associated with PTSD
screening status: 3.94(SD 0.88) and 3.87(SD 0.89) for PTSD1
and PTSD? patients, respectively (P=.08). Table 1 shows
baseline characteristics of respondents. Approximately 33%
(n=858) of the women screened positive for PTSD. Compared
with PTSD? women, PTSD1 women were significantly young-
er (M=41 vs 45), less likely to be married, more likely to have a
service-connected disability, and more likely to report irritable
bowel syndrome, fibromyalgia, and obesity as well as higher
rates of screening positive for current smoking, alcohol use
disorder, or depression. Despite being younger overall, PTSD1
women reported rates of hypertension, diabetes mellitus,
stroke, and other medical illness comparable to the women
without PTSD (Table 1). Mortality rates during the study did
not differ between PTSD groups.
8,646 total days hospitalized, with 3,985 days (46%) in acute
medical/surgical bed sections. Overall, 16% of the women were
hospitalized on acute medical/surgical wards during the
study: 20% and 14% of PTSD1 and PTSD? women, respec-
tively. Table 2 presents the mean number of days hospitalized
in medical/surgical wards/100 persons/y by PTSD screening
status, stratified by age. Posttraumatic stress disorder positive
women had higher inpatient medical/surgical utilization, par-
ticularly among women ages 35 to 49 (Table 2).
To evaluate whether these unadjusted associations between
PTSD and inpatient utilization reflected confounding because
of measured covariates, stepwise logistic regression analyses
were performed. In unadjusted analyses, PTSD screening sta-
tus was associated with an increased risk of medical/surgical
hospitalizations (OR=1.5; 95% CI=1.2 to 1.8), which persist-
ed after adjustment for age and smoking (OR=1.7; 1.3 to 2.1),
and remained significant in the model adjusted for potential
confounders, which included age, smoking, race, marital sta-
tus, education, service-connected status ?50%, stroke, can-
cer, and thyroid disease (OR=1.37; 1.04 to 1.79).
Hospitalizations. The studysamplehad
Inpatient Surgical Procedures. Among women under 50, the
incidence of inpatient surgical procedures, specifically gastro-
intestinal procedures, was higher for PTSD1 women (Table 3).
Among women over 50, there was no association between
PTSD screening status and the overall incidence of surgical
procedures; there were significantly more musculoskeletal
Table1. Baseline Characteristics by PTSD Screening Status
High school graduate or less
College graduate or more
Self-reported medical conditions
Irritable bowel syndrome
Current cigarette smoking
Alcohol use disorder screen
Depression screen positive
?Based on body mass index ?30 calculated from self-reported weight
PTSD, posttraumatic stress disorder, PTSD1, posttraumatic stress
disorder positive, PTSD?, posttraumatic stress disorder negative.
Table2. Comparison of Inpatient Medical or Surgical Utilization
Between Women who Screened Positive and Negative for PTSD:
Mean Days Hospitalized in the VA/100 Patients/Year
of Follow-Up (95% CI)?
178 132.6 (36.7 to 228.5)
85853.8 (31.9 to 75.7)
14.0 (7.8 to 20.1)
43.4 (26.1 to 60.7)
541 117.7 (84.5 to 150.9)
1720 47.9 (36.2 to 59.6)
14.1 (1.4 to 26.8)
17.0 (15.9 to 18.1)
?Age stratum-specific comparisons between PTSD1 and PTSD? women
were significant at Po.0001 for women o35 and those 35 to 49 years
old, whereas for women 50 years or older P=.81 (Wilcoxon’s rank sum
wPer 100 patients per year of follow-up.
PTSD, posttraumatic stress disorde; CI, confidence interval; PTSD1,
posttraumatic stress disorder positive; PTSD?, posttraumatic stress
Dobie et al., PTSD and Medical Utilization in Women
procedures among older PTSD1 women. Although all surgical
hospitalizations were included in the logistic regression model
above, inpatient surgical procedure subtypes were not sepa-
rately analyzed using logistic regression methods.
Table 4 presents the mean number of medical/surgical out-
patient visits per patient per year of follow-up. Within each
type of clinic, PTSD1 women had more VA outpatient clinic
visits than PTSD? women. These differences were statistically
significant across all 3 age groups (age-stratified data not pre-
sented). Table 5 shows the results of multivariate logistic re-
gression models used to evaluate whether these associations
between PTSD and outpatient utilization reflected confound-
ing based on other measured covariates. For each type of out-
patient utilization, we tested the association between PTSD1
screening status and being in the top quartile of utilization (the
quartile of patients with the highest numbers of visits). After
adjusting for age and smoking, the association between PTSD
and outpatient utilization was preserved across all clinic cat-
egories. With the exception of visits to medical and surgical
subspecialists, the association remained significant in the
fully adjusted models (Table 5).
Posttraumatic stress disorder and depression are highly
comorbid conditions.17Not unexpectedly, in our sample, 77%
of the women who screened positive for depression were
PTSD1, and 75% of the PTSD1 women screened positive for
depression. This resulted in a degree of colinearity too high to
allow placement of both variables in the same regression
model. In a secondary analysis, we compared the strength of
the association between PTSD1 and health care utilization
with the strength of the association between depression1 and
health care utilization. Using the previously described fully
adjusted models, we substituted MHI-5 depression screening
status into the last step instead of PTSD screening status.
Posttraumatic stress disorder screening status had a reliable
association with inpatient medical/surgical hospitalization
(OR=1.37; 1.04 to 1.79), whereas depression did not (OR=
1.21; 0.92 to 1.60). However, the CIs largely overlapped, sug-
gesting PTSD status and depression status were generally
comparable. Posttraumatic stress disorder and depression
were similarly comparable in predicting outpatient utilization
(data not presented).
This study of female VA patients found that PTSD1 women
were more likely than PTSD? women to be hospitalized for
medical or surgical conditions. Moreover, outpatient utiliza-
tion of ED, primary care, subspecialty care, ancillary services,
and diagnostic testing was higher among PTSD1 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.9,11–13Fewer studies have explored the association of
PTSD with health outcomes in female VA patients; such stud-
ies have relied primarily on self-report.14,25,26,32,46Our find-
ings 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.6,20,22,24,33,47Other investigators have used structur-
al equation modeling to conclude that PTSD is an important
mediator between trauma exposure and physical health in
Table3. Percent of Women Undergoing Inpatient Surgical Procedures During Follow-Up
Age o35yAge 35 to 49y Age ?50y
PTSD1 (n=238) PTSD? (n=473)P?
PTSD1 (n=442) PTSD? (n=706)P?
PTSD1 (n=178) PTSD? (n=541)P?
Any surgical procedures
?P, probability based on w2values.
PTSD, posttraumatic stress disorder; PTSD1, posttraumatic stress disorder positive; PTSD?, posttraumatic stress disorder negative.
Table4. Mean Number of Outpatient Visits Per Patient Per Year by
Type of Visit (with 95% Confidence Interval)
Type of VisitPTSD1 (n=858)PTSD? (n=1,720)P?
1.1 (1.0 to 1.2)0.6 (0.5 to 0.6)
3.2 (3.0 to 3.4)
2.1 (1.9 to 2.3)
2.2 (2.1 to 2.3)
1.5 (1.4 to 1.6)
4.1 (3.7 to 4.5)2.4 (2.2 to 2.6)
5.6 (5.1 to 6.1)3.7 (3.4 to 4.0)
?Probability based on Wilcoxon’s rank sum test.
wIncludes all medical and surgical subspecialty clinics staffed by MD or
Advanced Registered Nurse Practitioner (ARNP) providers.
zRepresents 35 clinic stop codes with services by provider other than MD
or ARNP: most common were physical therapy, dental, nursing follow-
up, podiatry, optometry, general social work, occupational therapy,
nutrition, homeless veteran health care outreach, VA-shared housing,
‰Outpatient diagnostic tests: laboratory, non-interventional radiology,
ultrasound, pulmonary function, ECG, MRI, EEG, nuclear medicine,
computerized tomography, electromyogram.
PTSD, posttraumatic stress disorder; PTSD1, posttraumatic stress
disorder positive; PTSD?, posttraumatic stress disorder negative.
Dobie et al., PTSD and Medical Utilization in Women
male veterans.28,33,35While our analyses cannot address
the presence of a causal association between PTSD and med-
ical 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 psy-
chiatric conditions in its association with increased health
care utilization. However, investigators have suggested that
physical health problems may be particularly prominent in
PTSD.21,23,25,48,49The 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 compli-
cates 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 (repre-
senting 89% of the women with PTSD) reported a greater bur-
den 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 pa-
tients and attribute increased treatment utilization to subjec-
tive physical distress in these patients.24,46,50,51Comorbid
conditions such as obesity, smoking, or substance abuse
could also contribute to poorer health in individuals with
PTSD.17,39Increased medical utilization may arise from inju-
ries 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,52a
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.28,35A recent
study of male veterans found a particularly robust association
between VA primary care clinic visits and PTSD in men under
the age of 52.31Similarly, 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
There are a number of limitations to this study. Partici-
pants 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 compa-
rable with women seen elsewhere for VA care.39,53Although it
is a validated screening instrument, the PCL-C is not a diag-
nostic interview for PTSD. Hence, our findings rely on a screen-
ing 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, espe-
cially in nonservice-connected women (who were also less like-
ly 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 con-
founding 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 prob-
lem within the growing population of women served by VA. Fi-
nally, our data do not evaluate the appropriateness of the care
received. Increased surgical utilization is of particular con-
cern, given its related morbidity and costs. Although evidence
suggests that VA provides high-quality care,54the appropri-
ateness 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,55the mental health consequences of the current conflict
are substantial.56Underutilization of VA mental health serv-
ices may be particularly apparent in women.57Thus, identifi-
cation of PTSD in VA primary care settings is crucial, as
specific and effective treatments for this condition are availa-
ble.58Future studies should focus on whether successful
treatment of PTSD will result in a decrease in medical utiliza-
tion. As more women serve in the military, the impact of PTSD
on women’s physical health presents an important consider-
ation for the design of VA health services.
This study is supported by grants from the Department of Vet-
erans Affairs: Health Services Research and Development Serv-
ice (GEN-97-022) and Epidemiology Research and Information
Center (LIP 61-114). Dr. Bradley is additionally supported by a
National Institutes of Alcoholism and Alcohol Abuse award
(K23AA00313) and was a Robert Wood Johnson Generalist
Physician Faculty Scholar at the time this work was complet-
ed. The views in this manuscript are those of the authors and
Table5. The Association of PTSD with High-Outpatient Utilization (Highest 25% of Users) of Various Outpatient Services
Variables in ModelEmergency DepartmentPrimary Care Sub-specialty Care Ancillary Services Diagnostic Tests
OR (95% CI)
PTSD unadjusted (n=2,578)
PTSD adjusted for age1smoking (n=2,541)
PTSD in fully adjusted models?(n=2,041)
2.41 (2.02 to 2.84)
2.33 (1.94 to 2.80)
2.04 (1.66 to 2.52)
1.65 (1.37 to 1.98) 1.44 (1.20 to 1.74) 1.96 (1.63 to 2.35) 1.73 (1.44 to 2.08)
1.79 (1.48 to 2.17) 1.58 (1.30 to 1.92) 2.11 (1.75 to 2.56) 1.95 (1.61 to 2.38)
1.30 (1.03 to 1.63) 1.09 (0.86 to 1.38) 1.66 (1.32 to 2.09) 1.54 (1.22 to 1.94)
?Full models all include age, smoking, and service-connected disability ?50%; Emergency Department model also includes education, marital status,
and BMI?30; Primary Care model also includes marital status, hypertension, irritable bowel syndrome, diabetes mellitus, cancer, education, thyroid
disease; Subspecialty Care model also includes diabetes mellitus, fibromyalgia, marital status, education, BMI?30, and irritable bowel syndrome;
Ancillary Services model also includes marital status, fibromyalgia, cancer, diabetes mellitus, prior stroke, and BMI?30; Diagnostic Tests model also
includes thyroid disease, diabetes mellitus, irritable bowel syndrome, marital status, BMI?30, and hepatitis.
PTSD, posttraumatic stress disorder; BMI, body mass index.
Dobie et al., PTSD and Medical Utilization in Women
do not necessarily represent the views of the Department of
1. Breslau N, Kessler RC, Shilcoat HD, Schultz LR, Davis GC, Andreski
PM. Trauma and posttraumatic stress disorder in the community: the
1996 Detroit area survey of trauma. Arch Gen Psychiatry. 1998;55:626–
2. Felitti VAR, Nordenberg D, Williamson DF, et al. Relationship of child-
hood abuse and household dysfunction to many of the leading causes of
death in adults: the adverse childhood experience (ACE) study. Am Prev
3. Shalev A, Freedman S, Peri T, et al. Prospective study of posttraumatic
stress disorder and comorbid major depression following trauma. Am J
4. Walker EA, Unutzer J, Rutter C, et al. Costs of health care use by
women HMO members with a history of childhood abuse and neglect.
Arch Gen Psychiatry. 1999;56:609–13.
5. Sibai AM, Armenian HK, Alam S. Wartime determinants of arterio-
graphically confirmed coronary artery disease in Beirut. Am J Epidemiol.
6. Boscarino JA. Diseases among men 20 years after exposure to severe
stress: implications for clinical research and medical care. Psychosom
7. Hankin CS, Skinner KM, Sullivan LM, Miller DR, Frayne S, Tripp TJ.
Prevalence of depressive and alcohol abuse symptoms among women VA
outpatients who report experiencing sexual assault while in the military.
J Trauma Stress. 1999;12:601–12.
8. Dobie DJ, Kivlahan DR, Maynard C, et al. Screening for post-traumatic
stress disorder in female Veteran’s Affairs patients: validation of the
PTSD checklist. Gen Hosp Psychiatry. 2002;24:367–74.
9. Sadler AG, Booth BM, Nielson D, Doebbeling BN. Health-related con-
sequences of physical and sexual violence: women in the military. Obstet
10. Engel CC, Engel AL, Campbell SJ, McFali ME, Russo J, Katon W.
PTSD symptoms; and precombat sexual and physical abuse in desert
storm veterans. J Nervous Mental Dis. 1993;683–8.
11. Suris A, Lind L, Kashner TM, Borman PD, Petty F. Sexual assault in
women veterans: an examination of PTSD risk, health care utilization,
and cost of care. Psychosom Med. 2004;66:749–56.
12. Stein MB, Lang AJ, Laffaye C, Satz LE, Lenox RJ, Dresselhaus TR.
Relationship of sexual assault history to somatic symptoms and health
anxiety in women. Gen Hosp Psychiatry. 2004;26:178–83.
13. Frayne SM, Skinner KM, Sullivan LM, et al. Medical profile of women
Veterans Administration outpatients who report a history of sexual as-
sault occurring while in the military. J Womens Health Gend Based Med.
14. Wolfe J, Schnurr PP, Brown PJ, Furey J. Posttraumatic stress disorder
and war-zone exposure as correlates of perceived health in female Viet-
nam war veterans. J Consult Clin Psychiatry. 1994;62:1235–40.
15. Murdoch M, Nichol KL. Women veterans’ experiences with domestic
violence and with sexual harassment while in the military. Arch Fam
16. American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders. 4th edn. Washington, DC: American Psychiatric
17. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttrau-
matic stress disorder in the National Comorbidity Survey. Arch Gen Psy-
18. Resnick HS, Kilpatrick DG, Dansky BS, Saunders BE, Best CL. Prev-
alence of civilian trauma and posttraumatic stress disorder in a repre-
sentative national sample of women. J Consult Clin Psychiatry.
19. Stein MB, McQuaid JR, Pedrelli P, Lenox R, McCahill ME. Posttrau-
matic stress disorder in the primary care medical setting. Gen Hosp Psy-
20. Schnurr PP, Friedman MJ, Sengupta A, Jankowski MK, Holmes T.
PTSD and utilization of medical treatment services among male Vietnam
veterans. J Nerv Ment Dis. 2000;188:496–504.
21. Zayfert C, Dums AR, Ferguson RJ, Hegel MT. Health functioning im-
pairments associated with posttraumatic stress disorder, anxiety disor-
ders, and depression. J Nerv Ment Dis. 2002;190:233–40.
22. Wagner AW, Wolfe J, Rotnitsky A, Proctor SP, Erickson DJ. An inves-
tigation of the impact of posttraumatic stress disorder on physical
health. J Trauma Stress. 2000;13:41–55.
23. WeisbergRB,BruceSE,Machan JT,KesslerRC,CulpepperL,KellerMB.
Nonpsychiatric illness among primary care patients with trauma histo-
24. Beckham JC, Moore SD, Feldman ME, Hertzberg MA, Kirby AC, Fair-
bank JA. Health status, somatization, and severity of posttraumatic
stress disorder in Vietnam combat veterans with posttraumatic stress
disorder. Am J Psychiatry. 1998;155:1565–9.
25. Frayne SM, Seaver MR, Loveland S, et al. Burden of medical illness in
women with depression and posttraumatic stress disorder. Arch Intern
26. Zatzick DF, Weiss DS, Marmar CR, et al. Post-traumatic stress disorder
and functioning and quality of life outcomes in female Vietnam veterans.
Mil Med. 1997;162:661–5.
27. Zatzick DF, Marmar CR, Weiss DS, et al. Posttraumatic stress disorder
and functioning and quality of life outcomes in a nationally representa-
tive sample of male Vietnam veterans. Am J Psychiatry. 1997;154:
28. Schnurr PP, Spiro A III, Paris AH. Physician-diagnosed medical disor-
ders in relation to PTSD symptoms in older male military veterans.
Health Psychol. 2000;19:91–7.
29. Ford JD, Campbell KA, Storzbach D, Binder LM, Anger WK, Rohlman
DS. Posttraumatic stress symptomatology is associated with unex-
plained illness attributed to Persian Gulf War military service. Psycho-
som Med. 2001;63:842–9.
30. Walker EA, Katon W, Russo J, Ciechanowski P, Newman E, Wagner
AW. Health care costs associated with posttraumatic stress disorder
symptoms in women. Arch Gen Psychiatry. 2003;60:369–74.
31. Calhoun PS, Bosworth HB, Grambow SC, Dudley TK, Beckham JC.
Medical service utilization by veterans seeking help for posttraumatic
stress disorder. Am J Psychiatry. 2002;159:2081–6.
32. Kimerling R, Clum GA, Wolfe J. Relationships among trauma exposure,
chronic posttraumatic stress disordersymptoms, and self-reported health
in women: replication and extension. J Trauma Stress. 2000;13:
33. Ford JD, Schnurr PP, Friedman MJ, Green BL, Adams G, Jex S. Post-
traumatic stress disorder symptoms, physical health, and health care
utilization 50 years after repeated exposure to a toxic gas. J Trauma
34. Friedman MJ, Schnurr PP. The relationship between trauma, post-trau-
matic stress disorder, and physical health. In: Friedman MJ, Charney
DS, Deutch AY, eds. Neurobiological and Clinical Consequences of
Stress: From Normal Adaption to PTSD. Philadelphia: Lippincott-Raven;
35. Deykin EY, Keane TM, Kaloupek D, et al. Posttraumatic stress
disorder and the use of health services. Psychosom Med. 2001;63:
36. Smith MV, Rosenheck RA, Cavaleri MA, Howell HB, Poschman K,
Yonkers KA. Screening for and detection of depression, panic disorder,
and PTSD in public-sector obstetric clinics. Psychiatric Serv. 2004;
37. Lecrubier Y. Posttraumatic stress disorder in primary care: a hidden
diagnosis. J Clin Psychiatry. 2004;65(suppl 1):49–54.
38. Grossman LS, Willer JK, Stovall JG, McRae SG, Maxwell S, Nelson R.
Underdiagnosis of PTSD and substance use disorders in hospitalized
female veterans. Psychiatric Serv. 1997;48:393–5.
39. Dobie DJ, Kivlahan DR, Maynard C, Bush KR, Davis TM, Bradley KA.
Posttraumatic stress disorder in female veterans: association with self-
reported health problems and functional impairment. Arch Intern Med.
40. Bradley KA, Bush KR, Davis TM, et al. Binge drinking among female
Veterans Affairs patients: prevalence and associated risks. Psychol
Addict Behav. 2001;15:297–305.
41. Weathers F, Ford J. Psychometric properties of the PTSD checklist (PCL-
C, PCL-S, PCL-M, PCL-PR). In: Stamm BH, ed. Measurement of Stress,
Trauma, and Adaptation. Lutherville, MD: Sidran Press; 1996.
42. Cowper DC, Kubal JD, Maynard C, Hynes DM. A primer and
comparative review of major U.S. mortality databases. Ann Epidemiol.
43. Berwick DM, Murphy JM, Goldman PA, Ware JE, Barsky AJ, Wein-
stein MC. Performance of a five-item mental health screening test. Med
Dobie et al., PTSD and Medical Utilization in Women
44. Russell M, Martier SS, Sokol RJ, et al. Screening for pregnancy risk-
drinking. Alcohol Clin Exp Res. 1994;18:1156–61.
45. Bush KR, Kivlahan DR, Davis TM, et al. The TWEAK is weak for alcohol
screening among female Veterans Affairs outpatients. Alcohol: Clin Exp
46. Escalona R, Achilles G, Waitzkin H, Yager J. PTSD and somatization
in women treated at a VA primary care clinic. Psychosomatics. 2004;
47. Marshall RP, Jorm AF, Grayson DA, O’Toole BI. Posttraumatic stress
disorder and other predictors of health care consumption by Vietnam
veterans. Psychiatric Serv. 1998;49:1609–11.
48. Fagan J, Galea S, Ahern J, Bonner S, Vlahov D. Relationship of self-
reported asthma severity and urgent health care utilization to psycho-
logical sequelae of the September 11, 2001 terrorist attacks on the World
Trade Center among New York City area residents. Psychosom Med.
49. Zhang W, Ross J, Davidson JR. Posttraumatic stress disorder in callers
to the Anxiety Disorders Association of America. Depress Anxiety.
50. Andreski P, Chilcoat H, Breslau N. Post-traumatic stress disorder and
somatization symptoms: a prospective study. Psychiatry Res. 1998;
51. van der Kolk BA, Pelcovitz D, Roth S, Mandel FS, McFarlane A, Her-
man JL. Dissociation, somatization, and affect dysregulation: the com-
plexity of adaptation to trauma. Am J Psychiatry. 1996;153:83–93.
52. Friedman MJ,Schnurr PP.
post-traumatic stress disorder, and physical health. In: MJ F, ed.
Neurobiological and Clinical Consequences of Stress: From Normal
Adaptation to PTSD. Philadelphia: Lippincott-Raven Publishers; 1995:
53. Skinner KM, Sullivan LM, Tripp TJ, et al. Comparing the health status
of male and female veterans who use VA health care: results from the VA
women’s health project. Women Health. 1999;29:17–33.
54. Asch SM, McGlynn EA, Hogan MM, et al. Comparison of quality of care
for patients in the Veterans Health Administration and patients in a na-
tional sample. Ann Intern Med. 2004;141:938–45.
55. Friedman MJ. Acknowledging the psychiatric cost of war. N Engl J Med.
56. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL.
Combat duty in Iraq and Afghanistan, mental health problems, and bar-
riers to care. N Engl J Med. 2004;351:13–22.
57. Hoff RA, Rosenheck RA. The use of VA and non-VA mental health serv-
ices by female veterans. Med Care. 1998;36:1524–33.
58. Foa EB, Meadows EA. Psychosocial treatments for posttraumatic stress
disorder: a critical review. Ann Rev Psychol. 1997;48:449–80.
The relationshipbetween trauma,
Voices of Women Veterans (continued)
HARASSMENT AND ABUSE
"In the 50s, there was some prejudice against women in the military, but for the most part I was
treated well. There were the usual passes made by men, but I handled it pretty well. Only once did I
report an incident and was backed up by my chief."
"I worked hard, became pregnant, and then lost the baby due to a miscarriage. My Commanding
Officer had no sympathy and repeatedly would say ’women should not be allowed to have
children if they are in the military,’ then would gloat about his wife being pregnant. I had gained a
few pounds due to the pregnancy and had a hard time taking it back off. I tried all kinds of diets
and even worked out during my lunch breaks. I was not allowed to receive awards I had achieved
nor be promoted due to the issue. Eventually, I tried to transfer out of my unit just to get away from
my CO. He denied them all. I became so depressed due to his badgering that I tried to commit
suicide. I was eventually honorably discharged, but I still wanted to serve my country. Being unable
to transfer without his authorization, I was forced to go home. Even with that, I still enjoyed serving
my country even as little as I did."
"In 1952, military careers were limited. I was schooled as a radio mechanic but was never allowed to
work in the field. The men refused to work with females."
Dobie et al., PTSD and Medical Utilization in Women