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Psychological comorbidity, or when mental health disorders co-occur, is an important health issue because it is common and may negatively affect quality of life and treatment for individuals with more than one disorder. In fact, approximately 80% of both civilians (Kessler et al., 1995) and active duty military service members (Walter et al., 2018) with posttraumatic stress disorder (PTSD) have a comorbid disorder. Some of the disorders that are most frequently comorbid with PTSD include major depressive disorder (MDD), adjustment disorder, generalized anxiety disorder (GAD), and alcohol use disorders (AUD). Further understanding which comorbid disorders most commonly present with PTSD—and among whom—is critical for developing treatments that directly address these symptom presentations to improve functioning for those with psychological comorbidity. 
One factor that may impact disorders comorbid with PTSD is gender. Research on single disorders has shown significant differences between women and men. For example, women are more likely than men to be diagnosed with internalizing disorders, such as MDD or GAD, whereas men have a greater likelihood of being diagnosed with externalizing disorders, such as AUD or antisocial behavior disorders (American Psychiatric Association, 2013; Curry et al., 2014; Kramer et al., 2008). Although research examining comorbid disorders with PTSD has been generally consistent with the research on single disorders, there are mixed findings in the literature, particularly in military samples. 
Understanding whether gender differences in PTSD and comorbid disorders exist may be particularly important among service members because women and men may be exposed to unique stressors. For instance, male service members may have greater exposure to combat (Vogt et al., 2011), while women may be more likely to experience military sexual trauma (Allard et al., 2011; Maguen et al., 2011). Improving our knowledge of potential gender differences in disorders comorbid with PTSD among service members can guide treatment development so that care delivery can be better tailored to those with PTSD and comorbid conditions. The aim of this study was to build on our prior work (Walter et al., 2018) by determining whether gender differences exist for PTSD and comorbid disorders using a large, population-based sample of active duty Sailors and Marines. Specifically, gender differences were examined for 14 conditions comorbid with PTSD. 
Overall, 83% of service members with a diagnosis of PTSD in their medical record also had a comorbid diagnosis, consistent with prior civilian and military research (Kessler et al., 1995; Walter et al., 2018). Study results showed that servicewomen (3.3%) were more likely to have a chart diagnosis of PTSD than servicemen (1.6%), which aligns with a large body of research showing that women are more likely than men to have PTSD. However, there were no differences between servicewomen and men in the likelihood of having any disorder comorbid with PTSD (84.3% vs. 82.9%, respectively). These findings indicate that among both servicewomen and men with a chart diagnosis of PTSD, a comorbid diagnosis is highly probable.
There were, however, significant gender differences in specific disorders comorbid with PTSD. Women in the military were more likely than men to have PTSD with adjustment disorder, MDD, and GAD or other anxiety disorders, with the strongest difference for eating and personality disorders. On the other hand, men in the military were more likely than women to have PTSD with comorbid AUD, drug use disorder, and insomnia, with the greatest effect in traumatic brain injury. For both servicewomen and men, depressive disorder was the most frequent comorbid disorder with PTSD, followed by adjustment, generalized anxiety, and AUD, which supported prior research (Crum-Cianflone et al., 2016; Walter et al., 2018; Hepner et al., 2016, 2018). Significant gender differences were not found for comorbid bipolar, obsessive compulsive, panic/phobic, psychotic, or somatoform/dissociative disorders, which all had low base rates in the sample.
In summary, comorbidity is the norm rather than the exception for those with PTSD, and many comorbidities differ by gender, highlighting the importance of comprehensive assessment in trauma-exposed populations. Also, given that there are a wide range of possibilities that could lead to gender differences in comorbid disorders with PTSD, future research is necessary. Furthermore, research exploring whether and how treatment outcomes differ based on comorbid disorders, sex or gender identification, and their interaction would provide important knowledge about whether existing treatments are sufficient or if modifications or adjunctive interventions could more optimally treat service members with PTSD. 

Reference Article 

Walter, K. H., Levine, J. A., Madra, N. J., Beltran, J. L., Glassman, L. H., & Thomsen, C. J. (2022). Gender difference in disorders comorbid with posttraumatic stress disorder among U.S. sailors and Marines. Journal of Traumatic Stresshttps://doi.org/10.1002/jts.22807

Discussion Questions 

  • How could the type of trauma exposure (e.g., military sexual trauma, combat) differentially affect disorders comorbid with PTSD? 
  • How might sex versus gender impact disorders comorbid with PTSD? In what ways might they be similar or different?
  • In what ways might these findings generalize to civilians or non-military populations? How might they differ?

About the Authors 

Kristen H. Walter, PhD, is a clinical research psychologist and division head of the Clinical Research Program at the Naval Health Research Center in San Diego, California. She is also a principal investigator on several Department of Defense-funded trials and a privileged clinical provider at Naval Medical Center San Diego. Her research focuses on the treatment of posttraumatic stress disorder (PTSD) and conditions that commonly co-occur with PTSD, such as major depressive disorder and traumatic brain injury, among active duty service members and veterans. Her work explores outcomes of evidence-based treatments for PTSD and comorbid conditions, as well as activity-based approaches. 
Jordan A. Levine, MPH, is an epidemiologist at the Naval Health Research Center in San Diego, California. Her research focuses on improving mental and behavioral health outcomes for members of the Armed Forces and their families. She also works in the global adolescent health sector, designing projects related to reproductive health, HIV, and economic inclusion.
Naju J. Madra, MA, is the content and instructional lead for the Military and Family Life Counseling Program (MFLC) and a Leidos contractor at the Naval Health Research Center in San Diego, California. Mrs. Madra brings over 20 years of behavioral health care experience, ranging from crisis counseling to residential treatment for individuals with severe mental illness and co-occurring disorders, to community college instruction and undergraduate counseling, to neuropsychological and PTSD assessment for veterans and active duty service members.
Jessica L. Beltran, BS, was a research associate and Leidos contractor at the Naval Health Research Center in San Diego, California. She assisted in conducting data collection, data entry, and analyses for multiple research projects studying mental health outcomes among active duty service members. She is currently a Master of Social Work student pursuing a career in mental health counseling in order to serve the needs of military service members, veterans, and their families.
Lisa H. Glassman, PhD, is a clinical and research psychologist and Leidos contractor working at the Naval Health Research Center in San Diego, California. Dr. Glassman's research is dedicated to increasing equitable access to evidence-based behavioral health care within active duty populations. Specifically, her research is focused on improving behavioral health symptoms, quality of life, resilience, and occupational performance, as well as improving the clinical effectiveness and efficiency of evidence-based interventions. She leverages technology (e.g., video teleconferencing, mobile apps) to improve treatment delivery, conducts program evaluations and clinical trials in understudied populations, and is an advocate for institutional change to ensure that evidence-based practices are effectively and broadly implemented. Dr. Glassman also has clinical expertise in the delivery of evidence-based psychological interventions for mood, anxiety, and trauma-related conditions.
Cindy J. Thomsen, PhD, is a research psychologist at the Naval Health Research Center in San Diego, California. For over twenty years, she has studied military stressors and their effects on service members’ mental and behavioral health. Dr. Thomsen’s research has focused on a range of adverse outcomes, including sexual, family, and workplace violence; suicidal behavior; impaired decision-making and performance; substance abuse; mental health problems such as posttraumatic stress disorder and depression; and health disparities. In addition to research focused on identifying risk and protective factors for psychological health issues, Dr. Thomsen and her team also develop and test interventions to prevent service members from developing health problems and to mitigate existing problems.

References Cited

Allard, C. B., Nunnink, S., Gregory, A. M., Klest, B., & Platt, M. (2011). Military sexual trauma research: A proposed agenda. Journal of Trauma & Dissociation12(3), 324–345. https://10.1080/15299732.2011.542609
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).https://doi.org/10.1176/appi.books.9780890425596

Crum-Cianflone, N. F., Powell, T. M., LeardMann, C. A., Russell, D. W., & Boyko, E. J. (2016). Mental health and comorbidities in U.S. military members. Military Medicine, 181(6), 537–545. https://doi.org/10.7205/MILMED-D-15-00187

Curry, J. F., Aubuchon-Endsley, N., Brancu, M., Runnals, J. J., VA Mid-Atlantic MIRECC Women Veterans Research Workgroup & VA Mid-Atlantic Registry Workgroup, & Fairbank, J. A. (2014). Lifetime major depression and comorbid disorders among current-era women veterans. Journal of Affective Disorders, 152, 434–440. https://doi.org/10.1016/j.jad.2013.10.012

Hepner, K. A., Roth, C. P., Sloss, E. M., Paddock, S. M., Iyiewuare, P. O., Timmer, M. J., & Pincus, H. A. (2018). Quality of care for PTSD and depression in the Military Health System: Final report. RAND Health Quarterly, 2018, 7(3), 4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5873521/

Hepner, K. A., Sloss, E. M., Paddock, S. M., & Roth, C. P. (2016). Quality of care for PTSD and depression in the Military Health System: Phase I report (No. RR-978-OSD). https://www.rand.org/pubs/research_reports/RR1542.html

Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry52, 1048–1060. https://doi.org/10.1001/archpsyc.1995.03950240066012

Kramer, M. D., Krueger, R. F., & Hicks, B. M. (2008). The role of internalizing and externalizing liability factors in accounting for gender differences in the prevalence of common psychopathological syndromes. Psychological Medicine38(1), 51–61. https://doi.org/10.1017/S0033291707001572

Maguen, S., Ren, L., Bosch, J. O., Marmar, C. R., & Seal, K. H. (2010). Gender differences in mental health diagnoses among Iraq and Afghanistan veterans enrolled in Veterans Affairs health care. American Journal of Public Health, 100(12), 2450–2456. https://doi.org/10.2105/AJPH.2009.166165

Vogt, D., Vaughn, R., Glickman, M. E., Schultz, M., Drainoni, M.-L., Elwy, R., & Eisen, S. (2011). Gender differences in combat-related stressors and their association with postdeployment mental health in a nationally representative sample of U.S. OEF/OIF veterans. Journal of Abnormal Psychology, 120(4), 797–806. https://doi.org/10.1037/a0023452

Walter, K. H., Levine, J. A., Highfill-McRoy, R. M., Navarro, M., & Thomsen, C. J. (2018). The prevalence of PTSD and psychological comorbidities among U.S. active duty service members, 2006-2013. Journal of Traumatic Stress31(6), 837–844. https://doi.org/10.1002/jts.22337

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