- The veteran population, about 18.5 million Americans in 2016 (US Census Bureau, 2018), is particularly at risk for mental health problems. As an example, the suicide rate of veterans is about one and a half times higher than the general population (US Department of Veteran Affairs [DVA], 2018b). Another group at risk for suicide are individuals in rural places (Hedegaard et al., 2018), representing about 20% of all Americans (US Census Bureau, 2016). Further, veterans appear to reside in more densely populated in rural areas, as 24% of all veterans, but only 20% of all Americans, live in rural places (US Census Bureau, 2016; Holder, 2017). Thus, rural veterans could be at an increased risk for mental health problems.
However, the literature about mental health differences, specifically posttraumatic stress disorder (PTSD), among rural and urban veterans is extremely mixed. Some research has shown that rural veterans are more likely to report a mental disorder (Proctor et al., 2011), have higher rates of PTSD (McCarthy et al., 2012), and were more likely to meet screening criteria for PTSD (Whealin et al., 2014). Other studies, however, have found that urban veterans are more likely to have PTSD (Cully et al., 2010; Mott et al., 2015; Wallace et al., 2006). However, Erickson et al. (2013) found no differences, once controlling for demographics.
There are also discrepancies concerning whether different war cohorts vary in their rates of PTSD. Fontana and Rosenheck (1994) found that Vietnam veterans had higher rates of PTSD when compared with Korean and World II veterans; however, a more recent comparison of war cohorts found that veterans of the most recent conflicts (i.e., Post-9/11) have the highest rates of PTSD, followed by Vietnam veterans, with World War II veterans having the least (IOM, 2013). The reasons for these discrepancies from both rural/urban and cohort comparisons are currently unclear but could result from differences in sample characteristics (e.g., community vs. patient samples, gender, SES, etc.), in cohort differences (e.g., differential combat exposure), or in how PTSD is reported (e.g., prevalence, incidence, positive screening, etc.).
This study has three hypotheses. (1) We hypothesize that rural veterans will have higher levels of PTSD symptoms, controlling for combat exposure and demographics; (2) veterans of the Post-9/11 cohort will have the highest PTSD symptoms; and (3) there will be a rural/urban status by war cohort interaction, with rural veterans of the Post-9/11 cohort having the highest PTSD symptoms. We examined factors that could contribute to these differences, specifically: age, gender, marital status, income, education, and combat exposure.
Participants came from Veterans Aging: Longitudinal studies in Oregon (VALOR) pilot study, (N=237; Mage = 58.16, SD = 12.58; completion rate = 75%) for this thesis. Participants completed a survey online, which measured the following: geographic location (RUCA; Washington State Department of Health, 2016), war cohort (screening question to participate in the study), combat exposure (CES; King et al., 2006), PTSD (PCL-5; Weathers et al., 2013), and demographics. Analyses of variance (ANOVAs) and analysis of covariance (ANCOVAs) were used to assess group differences and possible influences of demographic covariances, respectively. Parallel analyses were conducted using the entire sample and the combat-exposed subsample. Results from correlations resulted in the inclusion of the following covariates: age, gender, combat exposure, education, and income.
Correlational analyses showed that gender, age, and income were associated with PTSD, with men being higher, and older and higher income individuals having lower levels of PTSD symptoms, while educational attainment had no relationship. Curiously, in the whole sample, being in combat was inversely associated with PTSD, perhaps reflecting a “healthy warrior” effect, while combat severity was positively associated with PTSD in the subsample of combat veterans.
Contrary to our hypotheses, there were no differences in PTSD symptoms due to geographic location, either raw or adjusted, for either sample, probably because there were no demographic differences between the groups; this supported Erickson et al.’s (2013) finding. There was no effect of war cohort in unadjusted analyses, but covarying demographics showed that Vietnam veterans had significantly higher PTSD symptoms than both Persian Gulf and Post-9/11 veterans, contradicting the more recent IOM (2013) study. There were no significant interactions between geographic location and war cohort in PTSD symptoms for either sample, although rural Vietnam Veterans had twice as many PTSD symptoms as urban post-911 veterans.
However, this study uncovered an interesting conundrum, in which age was inversely associated with PTSD symptoms but the older cohort, the Vietnam Veterans, had the highest level of symptoms. Inspection of the distribution of PTSD symptoms by cohort showed that there was a small group of veterans in the oldest cohort which had very high symptom levels. This suggests that, while PTSD symptoms normatively decline with age, there may be a small minority that suffers from very high symptom levels in late life. Future longitudinal research is needed to determine whether this group suffered from life-long PTSD, or if there was a reemergence of PTSD in very late life.