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The Journal of Clinical Psychiatry The Journal of Clinical Psychiatry

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Original Research June 5, 2024

What’s Gender Got to Do With It: Accounting for Differences in Incident Guideline Discordant Prescribing for PTSD Among Women and Men Veterans

J Clin Psychiatry. 2024;85(2):23m15174

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Abstract

Objectives: Women veterans are more likely than men veterans to receive medications that Department of Veterans Affairs clinical practice guidelines recommend against to treat posttraumatic stress disorder (PTSD). To understand this difference, we examined potential confounders in incident prescribing of guideline discordant medications (GDMs) in veterans with PTSD.

Methods: Veterans receiving care for PTSD during 2020 were identified using Veterans Health Administration administrative data. PTSD diagnosis was established by the presence of at least 1 ICD-10 coded outpatient encounter or inpatient hospitalization during the calendar year 2020. Incident GDM prescribing was assessed during 2021, including benzodiazepines, antipsychotics, select anticonvulsants, and select antidepressants. Log-binomial regression was used to estimate the difference in risk for GDM initiation between men and women, adjusted for patient, prescriber, and facility-level covariates, and to identify key confounding variables.

Results: Of 704,699 veterans with PTSD, 16.9% of women and 10.1% of men initiated a GDM, an increased risk of 67% for women [relative risk (RR) = 1.67; 95% CI, 1.65–1.70]. After adjustment, the gender difference decreased to 1.22 (95% CI, 1.20–1.24) in a fully specified model. Three key confounding variables were identified: bipolar disorder (RR = 1.60; 95% CI, 1.57–1.63), age (<40 years: RR = 1.20 [1.18–1.22]; 40–54 years: RR = 1.13 [1.11–1.16]; ≥65 years: RR = 0.64 [0.62–0.65]), and count of distinct psychiatric medications prescribed in the prior year (RR = 1.14; 1.13–1.14).

Conclusions: Women veterans with PTSD were 67% more likely to initiate a GDM, where more than half of this effect was explained by bipolar disorder, age, and prior psychiatric medication. After adjustment, women veterans remained at 22% greater risk for an incident GDM, suggesting that other factors remain unidentified and warrant further investigation.

J Clin Psychiatry 2024;85(2):23m15174

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  1. Gradus JL, Suvak MK, Wisco BE, et al. Treatment of posttraumatic stress disorder reduces suicidal ideation. Depress Anxiety. 2013;30(10):1046–1053. PubMed CrossRef
  2. Olff M. Sex and gender differences in post-traumatic stress disorder: an update. Eur J Psychotraumatology. 2017;8(suppl 4):1351204.
  3. Street AE, Dardis CM. Using a social construction of gender lens to understand gender differences in posttraumatic stress disorder. Clin Psychol Rev. 2018;66:97–105. PubMed CrossRef
  4. Kimerling R, Allen MC, Duncan LE. Chromosomes to social contexts: sex and gender differences in PTSD. Curr Psychiatry Rep. 2018;20(12):114. PubMed CrossRef
  5. Kimerling R, Ouimette P, Weitlauf JC. Gender issues in PTSD. In: MJ Friedman, TM Keane, PA Resick, eds. Handbook of PTSD: Science and practice. The Guilford Press; 2007:207–228.
  6. Finley EP. Fields Of Combat: Understanding Post-Traumatic Stress Disorder Among Veterans of Iraq and Afghanistan. Emory University; 2009.
  7. Pineles SL, Arditte Hall KA, Rasmusson AM. Gender and PTSD: different pathways to a similar phenotype. Curr Opin Psychol. 2017;14:44–48. PubMed CrossRef
  8. Kessler RC, Petukhova M, Sampson NA, et al. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012;21(3):169–184. PubMed CrossRef
  9. Hadlandsmyth K, Bernardy NC, Lund BC. Gender differences in medication prescribing patterns for veterans with posttraumatic stress disorder: a 10-year follow-up study. J Trauma Stress. 2022;35(6):1586–1597. PubMed CrossRef
  10. Bernardy NC, Lund BC, Alexander B, et al. Gender differences in prescribing among veterans diagnosed with posttraumatic stress disorder. J Gen Intern Med. 2013;28(suppl 2):542–548. PubMed CrossRef
  11. Gross MM, Graham-Bermann SA. Gender, categories, and science-as-usual: a critical reading of gender and PTSD. Violence Against Women. 2006;12(4):393–406.
  12. Addis ME, Mahalik JR. Men, masculinity, and the contexts of help seeking. Am Psychol. 2003;58(1):5–14. PubMed CrossRef
  13. Gravely AA, Cutting A, Nugent S, et al. Validity of PTSD diagnoses in VA administrative data: comparison of VA administrative PTSD diagnoses to self reported PTSD Checklist scores. J Rehabil Res Dev. 2011;48(1):21–30. PubMed CrossRef
  14. Lund BC, Bernardy NC. Rural differences in psychiatric medication prescribing in veterans with posttraumatic stress disorder. J Rural Health. 2022;38(4):764–772. PubMed CrossRef
  15. Pratt AA, Hadlandsmyth K, Mengeling MA, et al. The impact of comorbid chronic pain on pharmacotherapy for veterans with post-traumatic stress disorder. J Clin Med. 2023;12(14):4763. PubMed CrossRef
  16. Management of Posttraumatic Stress Disorder Work Group. VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. U.S. Department of Veterans Affairs; 2017. Accessed February 15, 2024. https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf
  17. Mayhew M, DeBar LL, Deyo RA, et al. Development and assessment of a crosswalk between ICD-9-CM and ICD-10-CM to identify patients with common pain conditions. J Pain. 2019;20(12):1429–1445. PubMed CrossRef
  18. Tian TY, Zlateva I, Anderson DR. Using electronic health records data to identify patients with chronic pain in a primary care setting. J Am Med Inf Assoc. 2013;20(e2):e275–e280. PubMed CrossRef
  19. Mares JG, Lund BC, Adamowicz JL, et al. Differences in chronic pain care receipt among veterans from differing racialized groups and the impact of rural versus urban residence. J Rural Health. 2023;39(3):595–603. PubMed CrossRef
  20. Jolley RJ, Liang Z, Peng M, et al. Identifying cases of sleep disorders through International Classification of Diseases (ICD) codes in administrative data. Int J Popul Data Sci. 2018;3(1):448. PubMed CrossRef
  21. Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43(11):1130–1139. PubMed CrossRef
  22. Charlson ME, Carrozzino D, Guidi J, et al. Charlson comorbidity index: a critical review of clinimetric properties. Psychother Psychosom. 2022;91(1):8–35. PubMed
  23. Rothmiller SJ, Lund BC, Burgess DJ, et al. Race differences in veteran’s affairs emergency department utilization. Mil Med. 2022;188(11–12):3599–3605.
  24. Gaffey AE, Burg MM, Rosman L, et al. Baseline characteristics from the Women Veterans Cohort Study: gender differences and similarities in health and healthcare utilization. J Womens Health. 2021;30(7):944–955.
  25. Kelber MS, Liu X, O’Gallagher K, et al. Women in combat: the effects of combat exposure and gender on the incidence and persistence of posttraumatic stress disorder diagnosis. J Psychiatr Res. 2021;133:16–22. PubMed CrossRef
  26. Shiner B, Westgate CL, Bernardy NC, et al. Anticonvulsant medication use in veterans with posttraumatic stress disorder. J Clin Psychiatry. 2017;78(5):e545–e552. PubMed CrossRef
  27. Diflorio A, Jones I. Is sex important? Gender differences in bipolar disorder. Int Rev Psychiatry. 2010;22(5):437–452. PubMed CrossRef
  28. Dell’Osso B, Cafaro R, Ketter TA. Has Bipolar Disorder become a predominantly female gender related condition? Analysis of recently published large sample studies. Int J Bipolar Disord. 2021;9:3. PubMed
  29. ÓConghaile A, Smedberg DL, Shin AL, et al. Familial risk for psychiatric disorders in military veterans who have post-traumatic stress disorder with psychosis: a retrospective electronic record review. Psychiatr Genet. 2018;28(2):24–30. PubMed
  30. Okkels N, Trabjerg B, Arendt M, et al. Traumatic stress disorders and risk of subsequent schizophrenia spectrum disorder or bipolar disorder: a nationwide cohort study. Schizophr Bull. 2017;43(1):180–186. PubMed CrossRef
  31. Walter KH, Levine JA, Madra NJ, et al. Gender differences in disorders comorbid with posttraumatic stress disorder among US Sailors and Marines. J Trauma Stress. 2022;35(3):988–998. PubMed CrossRef
  32. Hourani L, Williams J, Bray R, et al. Gender differences in the expression of PTSD symptoms among active duty military personnel. J Anxiety Disord. 2015;29:101–108. PubMed CrossRef
  33. Tolin DF, Foa EB. Sex differences in trauma and posttraumatic stress disorder: a quantitative review of 25 years of research. APA PsycNet. 2008;S(1):37–85.
  34. Maguen S, Cohen B, Ren L, et al. Gender differences in military sexual trauma and mental health diagnoses among Iraq and Afghanistan veterans with posttraumatic stress disorder. Womens Health Issues. 2012;22(1):e61–e66. PubMed CrossRef
  35. Koo KH, Maguen S. Military sexual trauma and mental health diagnoses in female veterans returning from Afghanistan and Iraq: barriers and facilitators to veterans affairs care. Hastings Women’s LJ. 2014;25(1):27.
  36. Vogel DL, Wade NG, Hackler AH. Perceived public stigma and the willingness to seek counseling: the mediating roles of self-stigma and attitudes toward counseling. J Couns Psychol. 2007;54(1):40.
  37. Katz LS, Cojucar G, Beheshti S, et al. Military sexual trauma during deployment to Iraq and Afghanistan: prevalence, readjustment, and gender differences. Violence Vict. 2012;27(4):487–499. PubMed CrossRef
  38. Sadler AG, Cheney AM, Mengeling MA, et al. Servicemen’s perceptions of male sexual assault and barriers to reporting during active component and reserve/ national guard military service. J Interpers Violence. 2021;36(7–8):NP3596–NP3623. PubMed CrossRef
  39. Guina J, Nahhas RW, Kawalec K, et al. Are gender differences in DSM-5 PTSD symptomatology explained by sexual trauma? J Interpers Violence. 2019;34(21–22):4713–4740. PubMed CrossRef
  40. Sexton MB, Raggio GA, McSweeney LB, et al. Contrasting gender and combat versus military sexual traumas: psychiatric symptom severity and morbidities in treatment-seeking veterans. J Womens Health. 2017;26(9):933–940.
  41. Pulcino T, Galea S, Ahern J, et al. Posttraumatic stress in women after the September 11 terrorist attacks in New York City. J Womens Health. 2003;12(8):809–820. PubMed CrossRef
  42. Ho GWK, Hyland P, Karatzias T, et al. Traumatic life events as risk factors for psychosis and ICD-11 complex PTSD: a gender-specific examination. Eur J Psychotraumatol. 2021;12(1):2009271. PubMed CrossRef
  43. Harpaz-Rotem I, Rosenheck R, Mohamed S, et al. Initiation of pharmacotherapy for post-traumatic stress disorder among veterans from Iraq and Afghanistan: a dimensional, symptom cluster approach. BJPsych Open. 2016;2(5):286–293. PubMed CrossRef
  44. Johnson NL, Stewart Steffensmeier K, Garvin LA, et al. “It made me not want to see him…”: the role of patient-provider communication in influencing rural dwelling women veterans’ motivation to seek health care for managing chronic pain. Health Commun. 2024;39(6):1161–1174. PubMed
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