Pre-Pandemic Resilience to Trauma & COVID-19 Infection in Older Women.

OBJECTIVE: Prior work suggests psychological resilience to trauma may protect not only mental but also physical health. This study examined the relationship of pre-pandemic psychological resilience to lifetime trauma with self-reported COVID-19 infection and symptoms during the early years of the COVID-19 pandemic. METHODS: Data are from 18,670 longitudinal cohort participants in the Nurses' Health Study II. Based on prior evidence that trauma and subsequent distress can increase infection risk and severity, and that psychological assets may offset this risk, we hypothesized higher versus lower psychological resilience to prior trauma would be associated with lower risk for COVID-19 infection. Pre-pandemic resilience was assessed via self-report between 2017-2019 based on self-reported lifetime trauma exposure and psychological health. COVID-19 infection and symptoms were self-reported on 7 questionnaires administered between May 2020 - October 2021, from which we derived a composite outcome measure of probable COVID-19 infection, defined as having 3+ COVID-19 symptoms (out of 9) and/or a positive COVID-19 test result at any single assessment. RESULTS: Multivariable regression revealed significant associations between higher pre-pandemic resilience scores and lower risk for probable COVID-19 infection, adjusting for socio-demographic and COVID-19-related risk factors (RR = 0.90 [95% CI 0.87, 0.93]). Considering subcomponents of the composite COVID-19 infection measure separately, pre-pandemic resilience was significantly associated with lower risk of reported symptoms (RR = 0.83 [95% CI 0.79, 0.88]), but not with a positive test result alone (RR = 0.96 (95% CI 0.91, 1.01]). CONCLUSION: Identifying protective factors for infection risk may help inform psychosocial interventions to improve health outcomes.

Post-traumatic stress disorder symptom remission and cognition in a large cohort of civilian women.

BACKGROUND: Post-traumatic stress disorder (PTSD) is associated with cognitive impairments. It is unclear whether problems persist after PTSD symptoms remit. METHODS: Data came from 12 270 trauma-exposed women in the Nurses' Health Study II. Trauma and PTSD symptoms were assessed using validated scales to determine PTSD status as of 2008 (trauma/no PTSD, remitted PTSD, unresolved PTSD) and symptom severity (lifetime and past-month). Starting in 2014, cognitive function was assessed using the Cogstate Brief Battery every 6 or 12 months for up to 24 months. PTSD associations with baseline cognition and longitudinal cognitive changes were estimated by covariate-adjusted linear regression and linear mixed-effects models, respectively. RESULTS: Compared to women with trauma/no PTSD, women with remitted PTSD symptoms had a similar cognitive function at baseline, while women with unresolved PTSD symptoms had worse psychomotor speed/attention and learning/working memory. In women with unresolved PTSD symptoms, past-month PTSD symptom severity was inversely associated with baseline cognition. Over follow-up, both women with remitted and unresolved PTSD symptoms in 2008, especially those with high levels of symptoms, had a faster decline in learning/working memory than women with trauma/no PTSD. In women with remitted PTSD symptoms, higher lifetime PTSD symptom severity was associated with a faster decline in learning/working memory. Results were robust to the adjustment for sociodemographic, biobehavioral, and health factors and were partially attenuated when adjusted for depression. CONCLUSION: Unresolved but not remitted PTSD was associated with worse cognitive function assessed six years later. Accelerated cognitive decline was observed among women with either unresolved or remitted PTSD symptoms.

Metabolomic profiles of chronic distress are associated with cardiovascular disease risk and inflammation-related risk factors.

BACKGROUND: Chronic psychological distress is associated with increased risk of cardiovascular disease (CVD) and investigators have posited inflammatory factors may be centrally involved in these relationships. However, mechanistic evidence and molecular underpinnings of these processes remain unclear, and data are particularly sparse among women. This study examined if a metabolite profile linked with distress was associated with increased CVD risk and inflammation-related risk factors. METHODS: A plasma metabolite-based distress score (MDS) of twenty chronic psychological distress-related metabolites was developed in cross-sectional, 1:1 matched case-control data comprised of 558 women from the Nurses' Health Study (NHS; 279 women with distress, 279 controls). This MDS was then evaluated in two other cohorts: the Women's Health Initiative Observational Cohort (WHI-OS) and the Prevención con Dieta Mediterránea (PREDIMED) trial. We tested the MDS's association with risk of future CVD in each sample and with levels of C-reactive protein (CRP) in the WHI-OS. The WHI-OS subsample included 944 postmenopausal women (472 CHD cases; mean time to event = 5.8 years); the PREDIMED subsample included 980 men and women (224 CVD cases, mean time to event = 3.1 years). RESULTS: In the WHI-OS, a 1-SD increase in the plasma MDS was associated with a 20% increased incident CHD risk (odds ratio [OR] = 1.20, 95% CI: 1.04 - 1.38), adjusting for known CVD risk factors excluding total and HDL cholesterol. This association was attenuated after including total and HDL cholesterol. CRP mediated an average 12.9% (95% CI: 4.9% - 28%, p < 10-15) of the total effect of MDS on CHD risk when adjusting for matching factors. This effect was attenuated after adjusting for known CVD risk factors. Of the metabolites in the MDS, tryptophan and threonine were inversely associated with incident CHD risk in univariate models. In PREDIMED, each one SD increase in the MDS was associated with an OR of 1.19 (95% CI: 1.00 - 1.41) for incident CVD risk, after adjusting all risk factors. Similar associations were observed in men and women. Four metabolites in the MDS were associated with incident CVD risk in PREDIMED in univariate models. Biliverdin and C36:5 phosphatidylcholine (PC) plasmalogen had inverse associations; C16:0 ceramide and C18:0 lysophosphatidylethanolamine(LPE) each had positive associations with CVD risk. CONCLUSIONS: Our study points to molecular alterations that may underlie the association between chronic distress and subsequent risk of cardiovascular disease in adults.

Bereavement, Memorial Attendance, and Mental Health During the COVID-19 Pandemic: Longitudinal Results from the Nurses' Health Study.

BACKGROUND: Mortality increased during the COVID-19 pandemic. Many bereaved individuals were not able to gather to memorialize their loved ones, yet it is unknown if this contributed to worsening mental health. OBJECTIVE: Examine the association of bereavement in the early part of the COVID-19 pandemic with subsequent psychological distress and the role of memorial attendance in reducing psychological distress among the bereaved. DESIGN, SETTINGS, SUBJECTS: In May 2020, 39,564 older females from the Nurses' Health Study II enrolled in a longitudinal COVID-19 substudy (meanage = 65.2 years, SD = 4.5). METHODS: Linear regression analyses estimated associations of bereavement reported between March and October, 2020 with subsequent psychological distress between January and October 2021, adjusting for sociodemographic and prepandemic depression symptoms. Secondary models examined associations between memorial attendance and psychological distress. RESULTS: Bereavement during the early part of the COVID-19 pandemic was associated with higher psychological distress (adjusted ß = 0.21, 95% CI: 0.15, 0.26) assessed over the next year. Among the bereaved, memorial attendance was associated with lower psychological distress (in-person: adjusted ß = -0.41, 95% CI: -0.53, -0.29; online: adjusted ß = -0.24, 95% CI: -0.46, --0.02). CONCLUSION: Attending memorials was associated with lower subsequent psychological distress among bereaved older females.

Genetic Influences on Longitudinal Trajectories of Cortical Thickness and Surface Area during the First 2 Years of Life.

Genetic influences on cortical thickness (CT) and surface area (SA) are known to vary across the life span. Little is known about the extent to which genetic factors influence CT and SA in infancy and toddlerhood. We performed the first longitudinal assessment of genetic influences on variation in CT and SA in 501 twins who were aged 0-2 years. We observed substantial additive genetic influences on both average CT (0.48 in neonates, 0.37 in 1-year-olds, and 0.44 in 2-year-olds) and total SA (0.59 in neonates, 0.74 in 1-year-olds, and 0.73 in 2-year-olds). In addition, we found strong heritability of the change in average CT (0.49) from neonates to 1-year-olds, but not from 1- to 2-year-olds. Moreover, we found strong genetic correlations for average CT (rG = 0.92) between 1- and 2-year-olds and strong genetic correlations for total SA across all timepoints (rG = 0.96 between neonates and 1-year-olds, rG = 1 between 1- and 2-year-olds). In addition, we found CT and SA are strongly genetic correlated at birth, but weaken over time. Overall, results suggest a dynamic genetic relationship between CT and SA during first 2 years of life and provide novel insights into how genetic influences shape the cortical structure during early brain development.

Influence of gonadal steroids on cortical surface area in infancy.

Sex differences in the human brain emerge as early as mid-gestation and have been linked to sex hormones, particularly testosterone. Here, we analyzed the influence of markers of early sex hormone exposure (polygenic risk score (PRS) for testosterone, salivary testosterone, number of CAG repeats, digit ratios, and PRS for estradiol) on the growth pattern of cortical surface area in a longitudinal cohort of 722 infants. We found PRS for testosterone and right-hand digit ratio to be significantly associated with surface area, but only in females. PRS for testosterone at the most stringent P value threshold was positively associated with surface area development over time. Higher right-hand digit ratio, which is indicative of low prenatal testosterone levels, was negatively related to surface area in females. The current work suggests that variation in testosterone levels during both the prenatal and postnatal period may contribute to cortical surface area development in female infants.

Pre-pandemic resilience to trauma and mental health outcomes during COVID-19.

PURPOSE: The stress-sensitization hypothesis posits that individuals with prior trauma are at elevated risk for poor mental health when faced with subsequent stressors. Little work has examined whether those who have demonstrated psychological resilience to prior trauma would show either increased resilience or vulnerability to subsequent stressors. We examined pre-pandemic psychological resilience to lifetime trauma in relation to mental health outcomes amid the coronavirus disease 2019 (COVID-19) pandemic, a major societal stressor. METHODS: The sample included 16,900 trauma-exposed women from the Nurses' Health Study II. Pre-pandemic resilience was defined by psychological health in 2017-2019 (characterized by levels of both distress and positive emotional well-being) relative to lifetime trauma. Resilience was defined categorically by cross-classifying unfavorable, adequate, and favorable psychological health by higher versus lower trauma burden, and continuously as the residual difference in predicted versus actual psychological health regressed on trauma burden. Mental health outcomes as of May-August 2020 included psychological distress symptoms and overall positive emotional well-being. Associations were assessed using covariate-adjusted regression models. RESULTS: Pre-pandemic resilience was associated with lower distress and higher well-being early in the COVID-19 pandemic. Relative to the women showing highest resilience (favorable psychological health despite higher trauma), only those with lower trauma and favorable prior psychological health had significantly lower distress and higher positive emotional well-being during the pandemic. Higher continuous pre-pandemic resilience was also significantly associated with lower distress and higher positive emotional well-being during the pandemic. CONCLUSION: Preventing mental health problems following trauma may contribute to protecting population well-being amid major stressors.

Trauma, Post-Traumatic Stress Disorder, and Treatment Among Middle-Aged and Older Women in the Nurses' Health Study II.

OBJECTIVE: Trauma and post-traumatic stress disorder (PTSD) are common among women and associated with negative health outcomes across the life course. Relatively few studies, however, have examined the epidemiology of trauma, PTSD, and treatment among middle-aged and older civilian women, who are at elevated risk for adverse health outcomes. We aimed to characterize trauma, PTSD, and trauma-related treatment prevalence and correlates in a large cohort of middle-aged and older women. DESIGN: Cross-sectional, nested substudy within the Nurses' Health Study II cohort. SETTING: United States, 2018-2020. PARTICIPANTS: 33,327 current or former nurses, aged 53-74 years. MEASUREMENTS: 16-item modified version of the Brief Trauma Questionnaire; modified PTSD Checklist for the Diagnostic and Statistical Manual, Version 5. RESULTS: The majority (82.2%) of women reported one or more lifetime traumas. The most common trauma types were unexpected death of a loved one (44.9%) and interpersonal violence (43.5%). Almost 30% reported occupational (nursing-related) trauma. Among the trauma-exposed, 10.5% met criteria for lifetime PTSD and 1.5% had past-month PTSD. One-third of lifetime PTSD cases were due to interpersonal violence event types. One-third of women with lifetime PTSD-and nearly half of those with PTSD from a nursing-related trauma-reported never receiving trauma-related treatment. Women aged 65 years and older with PTSD were less likely to be in treatment than those aged less than 65 years. CONCLUSION: History of trauma and PTSD is prevalent in this population, and a treatment gap persists. Addressing this treatment gap is warranted, particularly among older women and those with nursing-related trauma.

The association of posttraumatic stress disorder, depression, and head injury with mid-life cognitive function in civilian women.

BACKGROUND: Despite evidence linking posttraumatic stress disorder (PTSD), depression, and head injury, separately, with worse cognitive performance, investigations of their combined effects on cognition are limited in civilian women. METHODS: The Cogstate Brief Battery assessment was administered in 10,681 women from the Nurses' Health Study II cohort, mean age 64.9 years (SD = 4.6). Psychological trauma, PTSD, depression, and head injury were assessed using online questionnaires. In this cross-sectional analysis, we used linear regression models to estimate mean differences in cognition by PTSD/depression status and stratified by history of head injury. RESULTS: History of head injury was prevalent (36%), and significantly more prevalent among women with PTSD and depression (57% of women with PTSD and depression, 21% of women with no psychological trauma or depression). Compared to having no psychological trauma or depression, having combined PTSD and depression was associated with worse performance on psychomotor speed/attention ( ß = -.15, p = .001) and learning/working memory ( ß = -.15, p < .001). The joint association of PTSD and depression on worse cognitive function was strongest among women with past head injury, particularly among those with multiple head injuries. CONCLUSIONS: Head injury, like PTSD and depression, was highly prevalent in this sample of civilian women. In combination, these factors were associated with poorer performance on cognitive tasks, a possible marker of future cognitive health. Head injury should be further explored in future studies of PTSD, depression and cognition in women.

Cortical Structure and Cognition in Infants and Toddlers.

Cortical structure has been consistently related to cognitive abilities in children and adults, yet we know little about how the cortex develops to support emergent cognition in infancy and toddlerhood when cortical thickness (CT) and surface area (SA) are maturing rapidly. In this report, we assessed how regional and global measures of CT and SA in a sample (N = 487) of healthy neonates, 1-year-olds, and 2-year-olds related to motor, language, visual reception, and general cognitive ability. We report novel findings that thicker cortices at ages 1 and 2 and larger SA at birth, age 1, and age 2 confer a cognitive advantage in infancy and toddlerhood. While several expected brain-cognition relationships were observed, overlapping cortical regions were also implicated across cognitive domains, suggesting that infancy marks a period of plasticity and refinement in cortical structure to support burgeoning motor, language, and cognitive abilities. CT may be a particularly important morphological indicator of ability, but its impact on cognition is relatively weak when compared with gestational age and maternal education. Findings suggest that prenatal and early postnatal cortical developments are important for cognition in infants and toddlers but should be considered in relation to other child and demographic factors.

Environmental Influences on Infant Cortical Thickness and Surface Area.

Cortical thickness (CT) and surface area (SA) vary widely between individuals and are associated with intellectual ability and risk for various psychiatric and neurodevelopmental conditions. Factors influencing this variability remain poorly understood, but the radial unit hypothesis, as well as the more recent supragranular cortex expansion hypothesis, suggests that prenatal and perinatal influences may be particularly important. In this report, we examine the impact of 17 major demographic and obstetric history variables on interindividual variation in CT and SA in a unique sample of 805 neonates who received MRI scans of the brain around 2 weeks of age. Birth weight, postnatal age at MRI, gestational age at birth, and sex emerged as important predictors of SA. Postnatal age at MRI, paternal education, and maternal ethnicity emerged as important predictors of CT. These findings suggest that individual variation in infant CT and SA is explained by different sets of environmental factors with neonatal SA more strongly influenced by sex and obstetric history and CT more strongly influenced by socioeconomic and ethnic disparities. Findings raise the possibility that interventions aimed at reducing disparities and improving obstetric outcomes may alter prenatal/perinatal cortical development.

Genetic influences on neonatal cortical thickness and surface area.

Genetic and environmental influences on cortical thickness (CT) and surface area (SA) are thought to vary in a complex and dynamic way across the lifespan. It has been established that CT and SA are genetically distinct in older children, adolescents, and adults, and that heritability varies across cortical regions. Very little, however, is known about how genetic and environmental factors influence infant CT and SA. Using structural MRI, we performed the first assessment of genetic and environmental influences on normal variation of SA and CT in 360 twin neonates. We observed strong and significant additive genetic influences on total SA (a2 = 0.78) and small and nonsignificant genetic influences on average CT (a2 = 0.29). Moreover, we found significant genetic overlap (genetic correlation = 0.65) between these global cortical measures. Regionally, there were minimal genetic influences across the cortex for both CT and SA measures and no distinct patterns of genetic regionalization. Overall, outcomes from this study suggest a dynamic relationship between CT and SA during the neonatal period and provide novel insights into how genetic influences shape cortical structure during early development.

Impact of Demographic and Obstetric Factors on Infant Brain Volumes: A Population Neuroscience Study.

Individual differences in neuroanatomy are associated with intellectual ability and psychiatric risk. Factors responsible for this variability remain poorly understood. We tested whether 17 major demographic and obstetric variables were associated with individual differences in brain volumes in 756 neonates assessed with MRI. Gestational age at MRI, sex, gestational age at birth, and birthweight were the most significant predictors, explaining 31% to 59% of variance. Unexpectedly, earlier born babies had larger brains than later born babies after adjusting for other predictors. Our results suggest earlier born children experience accelerated brain growth, either as a consequence of the richer sensory environment they experience outside the womb or in response to other factors associated with delivery. In the full sample, maternal and paternal education, maternal ethnicity, maternal smoking, and maternal psychiatric history showed marginal associations with brain volumes, whereas maternal age, paternal age, paternal ethnicity, paternal psychiatric history, and income did not. Effects of parental education and maternal ethnicity are partially mediated by differences in birthweight. Remaining effects may reflect differences in genetic variation or cultural capital. In particular late initiation of prenatal care could negatively impact brain development. Findings could inform public health policy aimed at optimizing child development.

Prior resilience to trauma & coping during the COVID-19 pandemic.

BACKGROUND AND OBJECTIVE: This study examined the potential influence of pre-pandemic psychological resilience on use of approach or avoidant coping styles and strategies to manage stress during the COVID-19 pandemic. We hypothesized that higher resilience would be associated with more approach coping and less avoidant coping. DESIGN AND METHODS: Longitudinal cohort data were from the Nurses' Health Study II, including 13,143 female current and former healthcare professionals with pre-pandemic lifetime trauma. Pre-pandemic resilience was assessed between 2018-2019 and current coping during the outbreak of the pandemic in the United States (May-August 2020). Multiple linear regression model results identified associations between continuous pre-pandemic resilience scores and use of approach and avoidant coping styles, as well as individual coping strategies, adjusting for relevant covariates. RESULTS: Greater resilience was associated with higher use of approach coping (ß = 0.06, 95% CI 0.05, 0.08) and lower use of avoidant coping styles (ß = -0.39, 95% CI -0.41, -0.38). Higher pre-pandemic resilience was also associated with use of eight (distraction [ß = -0.18, 95% CI -0.20, -0.16], substance use [ß = -0.15, 95% CI -0.17, -0.13], behavioral disengagement [ß = -0.29, 95% CI -0.30, -0.27], self-blame [ß = -0.44, 95% CI -0.45, -0.42], emotional support (ß = 0.03, 95% CI 0.01, 0.05), positive reframing [ß = 0.13, 95% CI 0.12, 0.15], humor [ß = 0.03, 95% CI 0.01, 0.05] and religion [ß = 0.06, 95% CI 0.04, 0.08]) of the nine coping strategies in expected directions. CONCLUSION: Findings have important implications for intervention or even prevention efforts to support vulnerable groups, such as women with prior trauma histories, during this and other immensely stressful times. Supporting or building psychological resilience following trauma may promote effective coping in times of future stress.

Intimate Partner Violence, Mental Health Symptoms, and Modifiable Health Factors in Women During the COVID-19 Pandemic in the US.

Importance: During the COVID-19 pandemic, the prevalence and severity of intimate partner violence (IPV) increased. Associations between IPV and mental health symptoms and modifiable health factors early in the pandemic have yet to be explored. Objective: To prospectively investigate the association of IPV with greater risk of mental health symptoms and adverse health factors during the COVID-19 pandemic in 3 cohorts of female participants. Design, Setting, and Participants: This cohort study used observational data from 3 prospective, population-based, longitudinal cohorts in the US: the Nurses' Health Study II, Growing Up Today Study, and Nurses' Health Study 3. Data analyzed included baseline and follow-up survey responses about IPV experiences early in the pandemic (March-September 2020); mental health domains of depression, anxiety, and posttraumatic stress symptoms (PTSS); and modifiable health factors (May 2020-October 2021). Female participants (both health care professionals and non-health care workers) aged 21 to 60 years from the 3 cohorts were included in the full analytic sample. Exposures: Experience of IPV measured by the Relationship Assessment Tool and fear of partner. Main Outcomes and Measures: Mental health symptoms, including depression, anxiety, and PTSS, and modifiable health factors, including sleep duration, sleep quality, physical activity, alcohol use, and use of alcohol or other substances to cope with stress. Results: The full analytic sample included 13 597 female participants with a mean (SD) age of 44 (10.6) years. Accounting for sociodemographic factors and prepandemic mental health symptoms and correcting for multiple testing, experiencing IPV was associated with higher endorsement of depression (odds ratio [OR], 1.44; 95% CI, 1.38-1.50), anxiety (OR, 1.31; 95% CI, 1.26-1.36), and PTSS (OR, 1.22; 95% CI, 1.15-1.29) in random-effects meta-analyses across the 3 cohorts. The IPV experience was also associated with poorer sleep quality (OR, 1.21; 95% CI, 1.16-1.26), shorter sleep duration (OR, 1.13; 95% CI, 1.08-1.19), increased use of alcohol (OR, 1.10; 95% CI, 1.06-1.14), and use of alcohol or other substances to cope with stress (OR, 1.13; 95% CI, 1.08-1.18) across all cohorts as well as decreased physical activity (OR, 1.17; 95% CI, 1.09-1.26) in the Nurses' Health Study II only. Conclusions and Relevance: Results of the study showed that IPV experiences at the start of the pandemic were associated with worse mental health symptoms and modifiable health factors for female participants younger than 60 years. Screening and interventions for IPV and related health factors are needed to prevent severe, long-term health consequences.

Psychological distress and metabolomic markers: A systematic review of posttraumatic stress disorder, anxiety, and subclinical distress.

Psychological distress can be conceptualized as an umbrella term encompassing symptoms of depression, anxiety, posttraumatic stress disorder (PTSD), or stress more generally. A systematic review of metabolomic markers associated with distress has the potential to reveal underlying molecular mechanisms linking distress to adverse health outcomes. The current systematic review extends prior reviews of clinical depressive disorders by synthesizing 39 existing studies that examined metabolomic markers for PTSD, anxiety disorders, and subclinical psychological distress in biological specimens. Most studies were based on small sets of pre-selected candidate metabolites, with few metabolites overlapping between studies. Vast heterogeneity was observed in study design and inconsistent patterns of association emerged between distress and metabolites. To gain a more robust understanding of distress and its metabolomic signatures, future research should include 1) large, population-based samples and longitudinal assessments, 2) replication and validation in diverse populations, 3) and agnostic metabolomic strategies profiling hundreds of targeted and nontargeted metabolites. Addressing these research priorities will improve the scope and reproducibility of future metabolomic studies of psychological distress.

Association of Posttraumatic Stress Disorder With Accelerated Cognitive Decline in Middle-aged Women.

Importance: Posttraumatic stress disorder (PTSD) has been hypothesized to lead to impaired cognitive function. However, no large-scale studies have assessed whether PTSD is prospectively associated with cognitive decline in middle-aged adults. Objective: To assess the association between PTSD and decline in cognitive function over time. Design, Setting, and Participants: This cohort study included participants from the Nurses' Health Study II, an ongoing longitudinal cohort study involving community-dwelling middle-aged female nurses residing in the US who had at least a 2-year nursing degree at the time of enrollment in 1989. The present study included 12 270 trauma-exposed women who were enrolled in the PTSD substudy of the Nurses' Health Study II and completed 1 to 5 cognitive assessments. Data were collected from March 1, 2008, to July 30, 2019. Exposures: Lifetime PTSD symptoms, assessed using a validated questionnaire between March 1, 2008, and February 28, 2010. Main Outcomes and Measures: The main outcome was evaluated using the Cogstate Brief Battery, a self-administered online cognitive battery. Cognitive function was measured by a psychomotor speed and attention composite score and a learning and working memory composite score. Women completed the Cogstate Brief Battery every 6 or 12 months (up to 24 months) from October 3, 2014, to July 30, 2019. Linear mixed-effects models were used to evaluate the association of PTSD symptoms with the rate of change in cognition over follow-up, considering a broad range of relevant covariates, including the presence of depression symptoms and history of clinician-diagnosed depression. The rate of cognitive change was adjusted for potential practice effects (ie, potential changes in test results that occur when a test is taken more than once) by including indicators for the number of previous tests taken. Results: Among 12 270 women, the mean (SD) age at the baseline cognitive assessment was 61.1 (4.6) years; 125 women (1.0%) were Asian, 75 (0.6%) were Black, 156 (1.3%) were Hispanic, 11 767 (95.9%) were non-Hispanic White, and 147 (1.2%) were of other race and/or ethnicity. A higher number of PTSD symptoms was associated with worse cognitive trajectories. Compared with women with no PTSD symptoms, women with the highest symptom level (6-7 symptoms) had a significantly worse rate of change in both learning and working memory (ß = -0.08 SD/y; 95% CI, -0.11 to -0.04 SD/y; P < .001) and psychomotor speed and attention (ß = -0.05 SD/y; 95% CI, -0.09 to -0.01 SD/y; P = .02), adjusted for demographic characteristics. Associations were unchanged when additionally adjusted for behavioral factors (eg, 6-7 symptoms in the analysis of learning and working memory: ß = -0.08 SD/y; 95% CI, -0.11 to -0.04 SD/y; P < .001) and health conditions (eg, 6-7 symptoms in the analysis of learning and working memory: ß = -0.08 SD/y; 95% CI, -0.11 to -0.04 SD/y; P < .001) and were partially attenuated but still evident when further adjusted for practice effects (eg, 6-7 symptoms in the analysis of learning and working memory: ß = -0.07 SD/y; 95% CI, -0.10 to -0.03 SD/y; P < .001) and comorbid depression (eg, 6-7 symptoms in the analysis of learning and working memory: ß = -0.07 SD/y; 95% CI, -0.11 to -0.03 SD/y; P < .001). Conclusions and Relevance: In this large-scale prospective cohort study, PTSD was associated with accelerated cognitive decline in middle-aged women, suggesting that earlier cognitive screening among women with PTSD may be warranted. Given that cognitive decline is strongly associated with subsequent Alzheimer disease and related dementias, better understanding of this association may be important to promote healthy aging.

Trauma, psychological distress and markers of systemic inflammation among US women: A longitudinal study.

BACKGROUND: Prior evidence links posttraumatic stress disorder (PTSD) and depression, separately, with chronic inflammation. However, whether effects are similar across each independently or potentiated when both are present is understudied. We evaluated combined measures of PTSD and depression in relation to inflammatory biomarker concentrations. METHODS: Data are from women (n's ranging 628-2797) in the Nurses' Health Study II. Trauma exposure, PTSD, and depression symptoms were ascertained using validated questionnaires. We examined (a) a continuous combined psychological distress score summing symptoms for PTSD and depression, and (b) a categorical cross-classified measure of trauma/PTSD symptoms/depressed mood status (reference group: no trauma or depressed mood). Three inflammatory biomarkers (C-reactive protein [CRP], interleukin-6 [IL-6], tumor necrosis factor alpha receptor 2 [TNFR2]) were assayed from at least one of two blood samples collected 10-16 years apart. We examined associations of our exposures with levels of each biomarker concentration (log-transformed and batch-corrected) as available across the two time points (cross-sectional analyses; CRP, IL-6 and TNFR2) and with rate of change in biomarkers across time (longitudinal analyses; CRP and IL-6) using separate linear mixed effects models. RESULTS: In sociodemographic-adjusted models accounting for trauma exposure, a one standard deviation increase in the continuous combined psychological distress score was associated with 10.2% (95% confidence interval (CI): 5.2-15.4%) higher CRP and 1.5% (95% CI: 0.5-2.5%) higher TNFR2 concentrations cross-sectionally. For the categorical exposure, women with trauma/PTSD symptoms/ depressed mood versus those with no trauma or depressed mood had 29.5% (95% CI: 13.3-47.9%) higher CRP and 13.1% (95% CI: 5.1-21.7%) higher IL-6 cross-sectionally. In longitudinal analysis, trauma/PTSD symptoms/depressed mood was associated with increasing CRP levels over time. CONCLUSIONS: High psychological distress levels with trauma exposure is associated with elevated inflammation and is a potential biologic pathway by which distress can impact development of inflammatory-related chronic diseases, such as cardiovascular disease. Considering multiple forms of distress in relation to these pathways may provide greater insight into who is at risk for biologic dysregulation and later susceptibility to chronic diseases.

Posttraumatic Stress Disorder and Likelihood of Hormone Therapy Use among Women in the Nurses' Health Study II: A 26-Year Prospective Analysis.

BACKGROUND: Posttraumatic stress disorder (PTSD) is associated with higher risk of certain chronic diseases, including ovarian cancer, but underlying mechanisms remain unclear. Although prior work has linked menopausal hormone therapy (MHT) use with elevated ovarian cancer risk, little research considers PTSD to likelihood of MHT use. We examined whether PTSD was prospectively associated with greater likelihood of initiating MHT use over 26 years. METHODS: Using data from the Nurses' Health Study II, with trauma and PTSD (symptoms and onset date) assessed by screener in 2008 and MHT assessed via biennial survey (from 1989), we performed Cox proportional regression models with women contributing person-years from age 36 years. Relevant covariates were assessed at biennial surveys. We considered potential effect modification by race/ethnicity, age at baseline, and period (1989-2002 vs. 2003-2015). RESULTS: Over follow-up, 22,352 of 43,025 women reported initiating MHT use. For example, compared with women with no trauma, the HR for initiating MHT was 1.18 for those with trauma/1-3 PTSD symptoms [95% confidence interval (CI), 1.13-1.22] and 1.31 for those with trauma/4-7 PTSD symptoms (95% CI, 1.25-1.36; P trend < 0.001), adjusting for sociodemographic factors. Associations were maintained when adjusting for reproductive factors and health conditions. We found evidence of effect modification by age at baseline. CONCLUSIONS: Trauma and number of PTSD symptoms were associated with greater likelihood of initiating MHT use in a dose-response manner. IMPACT: MHT may be a pathway linking PTSD to altered chronic disease risk. It is important to understand why women with PTSD initiate MHT use.