Psychological Health and Ischemic Heart Disease in Women: A Review of Current Evidence and Clinical Considerations across the Healthspan.

PURPOSE OF REVIEW: Psychological health encompasses a constellation of negative and positive factors-i.e., psychosocial stress, depression, anxiety, trauma, loneliness and social isolation, anger and hostility, optimism, and a sense of purpose. This narrative review presents current evidence at the intersection of psychological health, risk of ischemic heart disease (IHD), and IHD-related outcomes, with an emphasis on associations in women. RECENT FINDINGS: For women, relations between psychological health and IHD reflect important sex and gender differences in biological and psychosocial factors. Although efforts devoted to understanding psychological health and IHD risk have varied by psychological factor-scientific evidence is strongest for psychosocial stress and depression, while anxiety, trauma, and positive psychological factors warrant more investigation-less optimal psychological health is consistently associated with an earlier and greater risk of IHD morbidity and mortality in women. Still, many past prospective studies of psychological factors and IHD risk had a limited representation of women, did not include analyses by sex, or failed to account for other influential, sex-specific factors. Thus, there are multiple pathways for further, rigorous investigation into psychological health-IHD associations, mechanisms, and empirically supported psychological interventions to mitigate IHD risk among women. Given the robust evidence linking psychological health with women's risk for IHD, implementing routine, brief, psychological screening is recommended. Significant life events, developmental milestones specific to women, and IHD diagnoses or events could cue further psychological assessment and referral, efforts which will mutually strengthen the evidence for integrated psychological and IHD care and delivery of such care to this vulnerable group.

Female adolescents' early life stress and body mass index: Differential effects of anger and anxiety in response to rejection.

INTRODUCTION: Early life stress is linked to childhood obesity. As children enter adolescence, early life stress may be associated with increased rejection sensitivity, resulting in activation of behavioral and physiological changes that contribute to higher body mass index (BMI). Understanding the potential influence of rejection sensitivity on the association between early life stress and BMI is important to examine in female adolescents. For this secondary data analysis, we hypothesized that female adolescents with greater early life stress and greater rejection sensitivity would exhibit higher BMI-for-age 12 months later. METHODS: Seventy-eight adolescents (Mage = 13.1 years; 100% female sex; MBMI = 23.2 kg/m2) in the United States completed study procedures from 2012 to 2016. Among these procedures, the Psychosocial Schedule was used to assess cumulative early life stress and the Children's Rejection Sensitivity Questionnaire was used to assess anger and anxiety in response to rejection. Twelve months later, height and weight were measured to derive BMI-for-age. RESULTS: Higher early life stress was associated with higher BMI-for-age among female adolescents with low rejection-provoked anger (1 SD below the mean). However, this association was not observed among female adolescents with high rejection-provoked anger (1 SD above the mean). Finally, there was no significant interaction between early life stress and rejection-provoked anxiety in predicting BMI-for-age. CONCLUSIONS: Experiencing early life stress may interact with rejection-provoked anger, but not anxiety, to predict BMI-for-age. Findings inform a developmental perspective of how rejection sensitivity may influence the association between early life stress and early cardiometabolic risk.

The Perceived Stress Scale as a Measure of Stress: Decomposing Score Variance in Longitudinal Behavioral Medicine Studies.

BACKGROUND: The Perceived Stress Scale (PSS) is a widely used measure designed to assess perceptions of recent stress. However, it is unclear to what extent the construct assessed by the PSS represents factors that are stable versus variable within individuals, and how these components might vary over time. PURPOSE: Determine the degree to which variability in repeated PSS assessments is attributable to between-person versus within-person variance in two different studies and populations. METHODS: Secondary analyses utilized data from two studies with up to 13 PSS assessments: An observational study of 127 patients with heart failure followed over 39 months (Study 1), and an experimental study of 73 younger, healthy adults followed over 12 months (Study 2). Multilevel linear mixed modeling was used to estimate sources of variance in the PSS total and subscale scores across assessments. RESULTS: Between-person variance accounted for a large proportion of the total variance in PSS total scores in Study 1 (42.3%) and Study 2 (51.1%); within-person variance comprised the remainder. Between-person variance was higher for shorter assessment periods (e.g., 1 week), and was comparable when examining only the first 12 months of assessments in each study (52.9% vs. 51.1%). CONCLUSIONS: Within two samples differing in age and health status, between-person variance accounted for approximately half of the total variation in PSS scores over time. While within-person variance was observed, the construct assessed by the PSS may substantially reflect a more stable characteristic of how an individual perceives stressful life circumstances than previously appreciated.

The Perceived Stress Scale (PSS) is a widely used questionnaire designed to assess how an individual perceives recent stress in their life. It is unclear, however, the degree to which the PSS is measuring factors that are consistent within individuals versus those that fluctuate, and how these components might change when the PSS is administered repeatedly over time. To address this knowledge gap, data from two studies were used­a study of 137 patients with heart failure followed for 39 months and a study of 73 younger, healthy adults followed for 12 months. In each, participants completed up to 13 PSS assessments, with 2,880 total PSS assessments completed across the studies. Multilevel linear mixed modeling was used to examine sources of score variance across assessments. Between-person variance (i.e., score variability that is relatively stable over time but differs between individuals) accounted for approximately half of the total variation in PSS scores over time, and was higher over shorter assessment periods. While within-person variance was observed (i.e., score variability that fluctuates within the same individual over time), these results suggest that the PSS may assess a substantially more stable characteristic of how an individual perceives stressful life circumstances than previously appreciated.

Adolescent girls' cardiovascular responses to peer rejection: exploring the impact of early life stress.

Detrimental effects of early life stress on cardiovascular health are evident in adolescence. Cardiovascular reactivity and recovery in response to interpersonal stress may be a mechanism. This study aimed to evaluate if adolescent girls with higher early life stress demonstrated greater cardiovascular reactivity and slower recovery to peer rejection. A sample of 92 adolescent girls (age: M = 13.24) self-reported early life stressors. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were continuously measured before, during, and after a laboratory peer rejection paradigm. Counter to hypotheses, adolescent girls with higher early life stress had lower, not higher, HR during the recovery period. Early life stress was not associated with SBP or DBP recovery. Additionally, early life stress was not associated with SBP, DBP, or HR reactivity. Future research is needed to assess if blunted cardiovascular reactivity to interpersonal rejection during adolescence is a mechanism linking early life stress and later cardiovascular disease risk in women.

Gender Differences in Guideline-Directed Medical Therapy for Cardiovascular Disease Among Young Veterans.

BACKGROUND: There is an increasing burden of cardiovascular disease, including coronary artery disease (CAD) and heart failure (HF), among women Veterans. Clinical practice guidelines recommend multiple pharmacotherapies that can reduce risk of mortality and adverse cardiovascular outcomes. OBJECTIVE: To determine if there are disparities in the use of guideline-directed medical therapy by gender among Veterans with incident CAD and HF. DESIGN: Retrospective. PARTICIPANTS: Veterans (934,504; 87.8% men and 129,469; 12.2% women) returning from Operations Enduring Freedom, Iraqi Freedom, and New Dawn. MAIN MEASURES: Differences by gender in the prescription of Class 1, Level of Evidence A guideline-directed medical therapy among patients who developed incident CAD and HF at 30 days, 90 days, and 12 months after diagnosis. For CAD, medications included statins and antiplatelet therapy. For HF, medications included beta-blockers and renin-angiotensin-aldosterone system inhibitors. KEY RESULTS: Overall, women developed CAD and HF at a younger average age than men (mean 45.8 vs. 47.7 years, p<0.001; and 43.7 vs. 45.4 years, p<0.02, respectively). In the 12 months following a diagnosis of incident CAD, the odds of a woman receiving a prescription for at least one CAD drug was 0.85 (95% confidence interval [CI], 0.68-1.08) compared to men. In the 12 months following a diagnosis of incident HF, the odds of a woman receiving at least one HF medication was 0.54 (95% CI, 0.37-0.79) compared to men. CONCLUSIONS: Despite guideline recommendations, young women Veterans have approximately half the odds of being prescribed guideline-directed medical therapy within 1-year after a diagnosis of HF. These results highlight the need to develop targeted strategies to minimize gender disparities in CVD care to prevent adverse outcomes in this young and growing population.

Exploring the Impact of Maternal and Paternal Acceptance on Adolescent Girls' Emotion Regulation.

Maternal acceptance is associated with youth emotion regulation (a correlate of depression among adolescent girls); however, less is known about the impact of fathers. In this prospective study, we examined effects of maternal and paternal acceptance on youth sadness inhibition (a facet of emotion dysregulation) among adolescent girls (n = 82; Mage = 13.28; 43% from minoritized racial/ethnic groups) over 1 year. Youth varied on depression risk, which was assessed via clinical diagnostic interviews. Bivariate results showed that maternal acceptance was associated with lower youth sadness inhibition at baseline and 1-year follow-up, while paternal acceptance was only associated with lower youth sadness inhibition at 1-year follow-up. Step-wise regressions showed that paternal acceptance was inversely associated with youth sadness inhibition over time, above and beyond effects of youth age, baseline sadness inhibition, depression risk, and maternal acceptance. Findings highlight the importance of examining both mothers' and fathers' impact on adolescent girls' development of emotion regulation.

Posttraumatic Stress Disorder, Antidepressant Use, and Hemorrhagic Stroke in Young Men and Women: A 13-Year Cohort Study.

BACKGROUND AND PURPOSE: Antidepressants are commonly prescribed for posttraumatic stress disorder (PTSD) and may increase the risk of bleeding, including hemorrhagic stroke. METHODS: We prospectively examined independent effects of PTSD, selective serotonin and norepinephrine reuptake inhibitors (SSRI and SNRI) on the risk of incident hemorrhagic stroke in a nationwide sample of 1.1 million young and middle-aged veterans. Time-varying multivariate Cox models were used to examine hemorrhagic stroke risk by PTSD status and use of SSRI or SNRI while adjusting for demographics, lifestyle factors, stroke, and psychiatric comorbidities. Sensitivity analyses controlled for health care utilization. RESULTS: During 13 years of follow-up (2.14 years on average), 507 patients (12% women) suffered a hemorrhagic stroke. The overall incidence rate was 1.70 events per 10 000-person years. In unadjusted models, PTSD was associated with an 82% greater risk of new-onset hemorrhagic stroke (hazard ratio [HR], 1.82 [95% CI, 1.48-2.24]), SSRI use was associated with a >2-fold risk (HR, 2.02 [95% CI, 1.66-2.57]), and SNRI use was associated with a 52% greater risk (HR, 1.52 [95% CI, 1.08-2.16]). In fully adjusted models, effects of PTSD and SNRI were attenuated (adjusted HR, 1.03 [95% CI, 0.81-1.34]; adjusted HR, 1.19 [95% CI, 0.83-1.71]), but SSRI use remained associated with a 45% greater risk of hemorrhagic stroke (adjusted HR, 1.45 [95% CI, 1.13-1.85]). Hypertension, drug abuse, and alcohol abuse were also associated with increased stroke risk. Nonobesity and being non-Hispanic were protective factors. In sensitivity analyses, health care utilization was a small but significant predictor of stroke. CONCLUSIONS: In the largest known investigation of PTSD and antidepressant-associated risk for hemorrhagic stroke in young adults, use of SSRIs, but neither PTSD nor SNRIs were independently associated with incident stroke. SNRIs may be preferable for treating PTSD and comorbid conditions, although pursuing other modifiable risk factors and non-pharmacological treatments for PTSD also remains essential.

Perceived Stress, Subjective, and Objective Symptoms of Disturbed Sleep in Men and Women with Stable Heart Failure.

Objective/Background: Sleep disturbance is prevalent among patients with heart failure (HF) and is associated with increased morbidity and mortality. Stress also affects health and quality of life among patients with cardiovascular disease and likely plays a prominent role in HF. However, little is known about the associations between stress and sleep among HF patients.Participants: One hundred fifty-three stable New York Heart Association (NYHA) Classification I-IV HF patients with at least low symptoms of insomnia (Mage:63.0 ± 12.8, 42% Women).Methods: We examined baseline stress, sleep disturbance, and sleep-related characteristics from a randomized controlled trial of cognitive behavioral therapy for insomnia, including the Perceived Stress Scale, Insomnia Severity Index, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Sleep Disturbance Questionnaire, Dysfunctional Beliefs about Sleep Scale, PROMIS Cognitive Ability, SF-36 Mental Health, and wrist actigraphy. We used Pearson correlations and general linear models to assess stress-sleep associations, including the potential moderating effects of sex and symptom severity (NYHA).Results: There were moderate-to-large correlations between stress and self-reported sleep disturbance, dysfunctional beliefs about sleep, cognitive ability, and mental health (p's < 0.01). High stress was associated with more objectively-measured (i.e., actigraph-assessed) awakenings and sleep fragmentation among women than men (ß = - 0.04, p < 0.01; ß = - 0.71, p = 0.04). Relationships between stress and objectively-measured sleep did not vary by symptom severity.Conclusions: Perceived stress is related to sleep disturbance among HF patients, and effects may be sex-dependent. Subsequent research should determine the temporal links between sleep and stress, and optimal opportunities for intervention among HF patients.

High Rates of Menthol Cigarette Use Among Pregnant Smokers: Preliminary Findings and Call for Future Research.

INTRODUCTION: Smoking during pregnancy remains widespread and is causally associated with infant morbidity and mortality. Despite links between menthol cigarette use and decreased smoking cessation, little is known regarding rates or characteristics of pregnant menthol cigarette smokers. METHODS: Participants were drawn from two low-income, racially/ethnically diverse cohorts of pregnant smokers recruited from 2006 to 2015 (N = 166, Mage = 25 ± 5). Demographics, menthol cigarette use, daily cigarette use, quit status, and consecutive weeks quit were assessed by prospective interviews. Nicotine dependence was assessed using the Fagerström Test of Nicotine Dependence. Nicotine levels were assessed via saliva cotinine. RESULTS: High rates of menthol use were found in both cohorts (85% and 87%). Across both cohorts, menthol smokers were more likely to identify as racial/ethnic minorities, were less educated, and reported lower income than non-menthol smokers (ps < .03). Menthol smokers also reported fewer continuous weeks quit (8.4 vs. 14.5 weeks quit; p < .03) and a tendency toward decreased likelihood of quitting smoking over pregnancy (29% vs. 48%; p < .08) in unadjusted but not in covariate-adjusted analyses. No differences emerged in cigarettes per day, nicotine dependence or nicotine exposure. CONCLUSIONS: We found very high rates of menthol cigarette use in pregnant smokers-particularly among racial/ethnic minority and low socioeconomic status smokers-and some evidence for associations with reduced smoking cessation in pregnancy. Consideration of pregnant smokers as a uniquely vulnerable population is warranted in evaluating regulation of menthol in cigarettes. Further research is needed regarding the impact of menthol on smoking persistence in pregnancy and on maternal and infant health outcomes. IMPLICATIONS: This study highlights high rates of menthol cigarette use in pregnant women in the Northeast, United States, with evidence for higher rates of menthol use among racial/ethnic minority, less educated and low-income pregnant smokers, and preliminary evidence for associations between menthol cigarette use and reduced smoking cessation. Consideration of the effects of menthol on smoking persistence in pregnant women and on the health of their offspring is warranted in the development of regulations regarding menthol in cigarettes.

PTSD and the influence of context: The self as a social mirror.

The principal accepted models of posttraumatic stress disorder (PTSD) are based on both memory processing and biological/brain changes occurring when one's life or well-being is threatened. It is our thesis that these models would be greatly informed by community studies indicating that PTSD is predicted to a greater extent by earlier life experience and experiences that occur distant from the threatening event. These findings suggest posttraumatic responding is best conceptualized through the lens of the self-in-context, as opposed to imprinting that results from a given event at a given time. Moreover, studies of non-Western populations often do not express trauma as PTSD, or at least not primarily as PTSD, which argues against specific neural or memory encoding processes, but rather for a more plastic neural process that is shaped by experience and how the self develops in its cultural context, as a product of a broad array of experiences. We posit that fear and emotional conditioning as well as the ways traumas are encoded in memory are only partial explanatory mechanisms for trauma responding, and that issues of safety and harm, which are long term and developmental, are the common and principal underpinnings of the occurrence of posttraumatic distress, including PTSD.

Posttraumatic Stress Disorder and Risk for Stroke in Young and Middle-Aged Adults: A 13-Year Cohort Study.

Background and Purpose- In older populations, transient ischemic attack (TIA) and ischemic stroke have been linked to psychological factors, including posttraumatic stress disorder (PTSD). Whether PTSD also increases risk for early incident stroke in young adults is unknown. Methods- We prospectively assessed the incidence of TIA and ischemic stroke in a cohort of 987 855 young and middle-aged Veterans (mean age of 30.29±9.19 years; 87.8% men, 64.4% white) who first accessed care through the Veterans Health Administration from October 2001 to November 2014 and were free of TIA and ischemic stroke at baseline. For each outcome, time-varying multivariate Cox models were constructed to examine the effect of PTSD on incident stroke. We also assessed for effect modification by sex. Additional sensitivity analyses controlled for healthcare utilization. Results- Over a 13-year period, TIA and ischemic stroke were diagnosed in 766 and 1877 patients, respectively. PTSD was diagnosed in 28.6% of the sample during follow-up. In unadjusted analyses, PTSD was significantly associated with new-onset TIA (hazard ratio [HR], 2.02; 95% CI, 1.62-2.52) and ischemic stroke (HR, 1.62; 95% CI, 1.47-1.79). In fully adjusted models, the association between PTSD and incident TIA (HR, 1.61; 95% CI, 1.27-2.04) and ischemic stroke (HR, 1.36; 95% CI, 1.22-1.52) remained significant. The effect of PTSD on ischemic stroke risk was stronger in men than in women (HR, 0.63; 95% CI, 0.47-0.86; P=0.003), but no effect of sex was found for TIA. Conclusions- PTSD is associated with a significant increase in risk of early incident TIA and ischemic stroke independent of established stroke risk factors, coexisting psychiatric disorders, and healthcare utilization. Sex moderated the relationship for adults with ischemic stroke but not TIA. These findings suggest that psychological factors, including PTSD, may be important targets for future age-specific prevention strategies for young adults.

Stress through the mind of the beholder: preliminary differences in child and maternal perceptions of child stress in relation to child cortisol and cardiovascular activity.

The present study examined associations among parent and child reports of youth's stressful life events (SLEs), perceived stress, and biological measures of stress activity (i.e. cortisol and cardiovascular activity). Examining these aspects of youth stress presents several challenges. Unlike adult studies of individual differences in which information regarding SLEs, perceptions of events, and biological activity are gathered from one individual, assessment of individual differences among children usually involves other informants (e.g. parent). However, parent and child reports of SLEs and the child's psychological response to such events are often discordant. Moreover, examinations of youth perception of stress are hampered by limitations of child cognitive processes, as well as parents' limited knowledge of their child's perception of stress. In a preliminary effort to unscramble the complex effects of youth SLEs and perceived stress in relation to biological response to acute stressors, this study examined 51 boys and girls aged 7-16, with no history of psychopathology or medical concerns. Contrary to hypotheses, findings revealed that compared to actual experiences of stress, perceived stress has greater associations with both cortisol and cardiovascular activity. That is, perceived stress is more biologically salient relative to actual stress. Results also suggest that informant differences may explain some previous inconsistent findings in studies of youth's stress reactivity. The current findings mirror the adult studies that show appraisal and perception of traumatic and stressful events may be more predictive of negative health and mental health outcomes than the severity of the events. Further studies are needed to understand the impact of youth's perceptions of stress on their biological stress reactions and later health outcomes such as clinical disorders.

Effects of intranasal oxytocin on steroid hormones in men and women.

BACKGROUND: Recent interest in the social and cognitive effects of intranasal oxytocin prompts a need for understanding its physiological effects in humans. Few studies have examined the effects of intranasal oxytocin on steroid hormones. Filling this gap is especially important given the evidence that steroid hormones participate in some of the same behavioral functions as oxytocin, e.g. in stress, processing of emotional stimuli, aggression, trust, empathy, and parental care. METHODS: In randomized, double-blind experiments, we administered oxytocin (24 IU) or saline placebo to 97 healthy participants. Saliva samples were collected before and at several time points after the oxytocin/placebo administration to assess the levels of cortisol, progesterone, and testosterone. RESULTS: Oxytocin had no effects on testosterone, progesterone, or cortisol in women or men. CONCLUSION: Acute intranasal oxytocin does not affect the levels of cortisol, testosterone or progesterone in humans, at least in the absence of a stressful context. These data suggest that acute oxytocin does not have a direct impact on the human hypothalamic-pituitary-adrenal or hypothalamic-pituitary-gonadal axes under nonstressful circumstances. This knowledge helps rule out potential mechanisms for some of the effects of oxytocin in humans and adds to the generally limited body of knowledge on the basic physiological or psychological effects of intranasal oxytocin in human beings.

Circulating cortisol levels after exogenous cortisol administration are higher in women using hormonal contraceptives: data from two preliminary studies.

Exogenous cortisol administration has been used to test the influence of glucocorticoids on a variety of outcomes, including memory and affect. Careful control of factors known to influence cortisol and other endogenous hormone levels is central to the success of this research. While the use of hormonal birth control (HBC) is known to exert many physiological effects, including decreasing the salivary cortisol response to stress, it is unknown how HBC influences circulating cortisol levels after exogenous cortisol administration. To determine those effects, we examined the role of HBC on participants' cortisol levels after receiving synthetic cortisol (hydrocortisone) in two separate studies. In Study 1, 24 healthy women taking HBC and 26 healthy men were administered a 0.1 mg/kg body weight intravenous dose of hydrocortisone, and plasma cortisol levels were measured over 3 h. In Study 2, 61 participants (34 women; 16 were on HBC) received a 15 mg hydrocortisone pill, and salivary cortisol levels were measured over 6 h. Taken together, results from these studies suggest that HBC use is associated with a greater cortisol increase following cortisol administration. These data have important methodological implications: (1) when given a controlled dose of hydrocortisone, cortisol levels may increase more dramatically in women taking HBC versus women not on HBC or men; and (2) in studies manipulating cortisol levels, women on hormonal contraceptives should be investigated as a separate group.

Electronic Health Record Concordance with Survey-Reported Military Sexual Trauma Among Younger Veterans: Associations with Health Care Utilization and Mental Health Diagnoses.

Introduction: Military sexual trauma (MST) is more common among post-9/11 Veterans and women versus older Veterans and men. Despite mandatory screening, the concordance of electronic health record (EHR) documentation and survey-reported MST, and associations with health care utilization and mental health diagnoses, are unknown for this younger group. Materials and Methods: Veterans' Health Administration (VHA) EHR (2001-2021) were merged with data from the observational, nationwide WomenVeterans Cohort Study (collected 2016-2020, n = 1058; 51% women). Experiencing MST was defined as positive endorsement of sexual harassment and/or assault. From the EHR, we derived Veterans' number of primary care and mental health visits in the initial two years of VHA care and diagnoses of posttraumatic stress disorder (PTSD), depression, and anxiety. First, the concordance of EHR MST screening and survey-reported MST was compared. Next, multivariate analyses tested the cross-sectional associations of EHR screening and survey-reported MST with Veterans' health care utilization, and compared the likelihood of PTSD, depression, and anxiety diagnoses by MST group, while covarying demographics and service-related characteristics. With few MST cases among men, multivariate analyses were only pursued for women. Results: Overall, 29% of women and 2% of men screened positive for MST in the EHR, but 64% of women and 9% of men had survey-reported MST. Primary care utilization was similar between women with concordant, positive MST reports in the EHR and survey versus those with survey-reported MST only. Women with survey-reported MST only were less likely to have a PTSD or depression diagnosis than those with concordant, positive MST reports. There was no group difference in women's likelihood of anxiety. Conclusions: EHR MST documentation is discordant for many post-9/11 Veterans-both for men and women. Improving MST screening and better supporting MST disclosure are each critical to provide appropriate and timely care for younger Veterans, particularly women.

Blood Pressure Control and Maintenance in a Prospective Cohort of Younger Veterans: Roles of Sex, Race, Ethnicity, and Social Determinants of Health.

Background: Proactive blood pressure (BP) management is particularly beneficial for younger Veterans, who have a greater prevalence and earlier onset of cardiovascular disease than non-Veterans. It is unknown what proportion of younger Veterans achieve and maintain BP control after hypertension onset and if BP control differs by demographics and social deprivation. Methods: Electronic health records were merged from Veterans who enrolled in VA care 10/1/2001-9/30/2017 and met criteria for hypertension - first diagnosis or antihypertensive fill. BP control (140/90 mmHg), was estimated 1, 2, and 5 years post-hypertension documentation, and characterized by sex, race, and ethnicity. Adjusted logistic regressions assessed likelihood of BP control by these demographics and with the Social Deprivation Index (SDI). Results: Overall, 17% patients met criteria for hypertension (n=198,367; 11% of women, median age 41). One year later, 59% of men and 65% of women achieved BP control. After adjustment, women had a 72% greater odds of BP control than men, with minimal change over 5 years. Black adults had a 22% lower odds of BP control than White adults. SDI did not significantly change these results. Conclusions: In the largest study of hypertension in younger Veterans, 41% of men and 35% of women did not have BP control after 1 year, and BP control was consistently better for women through 5 years. Thus, the first year of hypertension management portends future, long-term BP control. As social deprivation did not affect BP control, the VA system may protect against disadvantages observed in the general U.S. population.

Depression, Insomnia, and Obesity Among Post-9/11 Veterans: Eating Pathology as a Distinct Health Risk Behavior.

INTRODUCTION: Understanding the interrelationships between co-occurring chronic health conditions and health behaviors is critical to developing interventions to successfully change multiple health behaviors and related comorbidities. The objective of the present study was to examine the effects of depression, insomnia, and their co-occurrence on risk of obesity and to examine the role of health risk behaviors as potential confounders of these relationships with an emphasis on eating pathologies. METHODS: Iraq and Afghanistan conflict era veterans (n = 1,094, 51.2% women) who participated in the Women Veterans Cohort Study between July 2014 and September 2019 were categorized as having depression, insomnia, both, or neither condition. Logistic regression models were used to examine group differences in the risk of obesity. Health risk behaviors (i.e., eating pathology, physical activity, smoking, and hazardous drinking) were then assessed as potential confounders of the effects of depression and insomnia on the likelihood of obesity. RESULTS: Obesity was most prevalent in individuals with co-occurring insomnia and depression (53.2%), followed by depression only (44.6%), insomnia only (38.5%), and neither condition (30.1%). Importantly, maladaptive eating behaviors confounded the depression-obesity association but not the insomnia-obesity association. There was no evidence that insufficient physical activity, smoking, or hazardous drinking confounded the effects of insomnia or depression on obesity. CONCLUSIONS: These findings exemplify the complex relationships between multiple health conditions and behaviors that contribute to obesity. Elucidating these associations can enhance the precision with which interventions are tailored to efficiently allocate resources and reduce the severe health impact of obesity among veterans.

Post-9/11 deployment history and the incidence of breast cancer among women veterans.

PURPOSE: To determine if women Veterans who deployed in support of Operations Enduring Freedom/Iraqi Freedom (OEF/OIF) would show a greater likelihood of breast cancer (BC) than other women Veterans. METHODS: This was a retrospective cohort study of women aged <60 years who received Veterans Affairs medical center primary care, 2001-2021. The exposure was OEF/OIF deployment and the outcome was a BC diagnosis after entering Veterans Affairs care. Poisson models evaluated the association between deployment and BC incidence, covarying demographics, lifestyle factors, and hormonal contraceptive and hormone replacement therapy use. Analyses were also stratified by age and race, and a sensitivity analysis adjusted for healthcare utilization over the initial 2 years. RESULTS: Of 576,601 women, 24.6% (n = 141,935) deployed during post-9/11 conflicts. Across follow-up [median: 8.2 years], 1.2% women were diagnosed with BC. Those who deployed in support of OEF/OIF were 23% less likely to be diagnosed with BC than women who did not deploy (95% CI: 0.73, 0.86). The association remained in stratified models and when including healthcare utilization. CONCLUSIONS: Despite the exposures of OEF/OIF deployment, there was a significantly lower incidence of BC among women who deployed versus not, possibly due to a healthy soldier effect or to differences in screening.

Insomnia and Early Incident Atrial Fibrillation: A 16-Year Cohort Study of Younger Men and Women Veterans.

Background There is growing consideration of sleep disturbances and disorders in early cardiovascular risk, including atrial fibrillation (AF). Obstructive sleep apnea confers risk for AF but is highly comorbid with insomnia, another common sleep disorder. We sought to first determine the association of insomnia and early incident AF risk, and second, to determine if AF onset is earlier among those with insomnia. Methods and Results This retrospective analysis used electronic health records from a cohort study of US veterans who were discharged from military service since October 1, 2001 (ie, post-9/11) and received Veterans Health Administration care, 2001 to 2017. Time-varying, multivariate Cox proportional hazard models were used to examine the independent contribution of insomnia diagnosis to AF incidence while serially adjusting for demographics, lifestyle factors, clinical comorbidities including obstructive sleep apnea and psychiatric disorders, and health care utilization. Overall, 1 063 723 post-9/11 veterans (Mean age=28.2 years, 14% women) were followed for 10 years on average. There were 4168 cases of AF (0.42/1000 person-years). Insomnia was associated with a 32% greater adjusted risk of AF (95% CI, 1.21-1.43), and veterans with insomnia showed AF onset up to 2 years earlier. Insomnia-AF associations were similar after accounting for health care utilization (adjusted hazard ratio [aHR], 1.27 [95% CI, 1.17-1.39]), excluding veterans with obstructive sleep apnea (aHR, 1.38 [95% CI, 1.24-1.53]), and among those with a sleep study (aHR, 1.26 [95% CI, 1.07-1.50]). Conclusions In younger adults, insomnia was independently associated with incident AF. Additional studies should determine if this association differs by sex and if behavioral or pharmacological treatment for insomnia attenuates AF risk.