Correlates of Lifetime Exposure to One or More Potentially Traumatic Events and Subsequent Posttraumatic Stress among Adults in the United States: Results from the Mental Health Surveillance Study, 2008-2012

1. Introduction

With growing recognition of the impact of trauma exposure on behavioral health outcomes, the Substance Abuse and Mental Health Services Administration (SAMHSA) is interested in defining and measuring trauma, describing the characteristics of those exposed to one or more potentially traumatic events (PTEs), and examining associations with mental health and substance use issues. SAMHSA has developed a strategic initiative to develop a comprehensive public health approach to trauma, with the knowledge that posttraumatic stress is treatable with appropriate and early intervention to mitigate the potential for deleterious effects after trauma exposure.¹ This strategy focuses on integrating trauma-informed approaches to effectively address the needs of people with behavioral health problems and teaming with partners to improve prevention, screening, and treatment for trauma and subsequent posttraumatic stress.

The 2008-2012 National Survey on Drug Use and Health (NSDUH) Mental Health Surveillance Study (MHSS) defined and measured posttraumatic stress disorder (PTSD) as part of an effort to estimate serious mental illness among adults in the U.S. civilian, noninstitutionalized population. The module on PTSD collected as part of the MHSS can be used to measure lifetime exposure to one or more PTEs, as well as subsequent posttraumatic stress symptoms (PTSS), including symptom clusters that meet criteria for past year PTSD among adults. This report uses NSDUH and MHSS data to examine the characteristics of adults exposed to one or more lifetime PTEs and adults who experience subsequent PTSS and to study the association among PTEs, PTSS, and physical and behavioral health conditions.

It should be noted that many individuals with exposure to one or more lifetime PTEs do not experience posttraumatic stress such as re-experiencing the traumatic event or having avoidance and hyperarousal responses to the traumatic event. Among individuals who do develop posttraumatic stress after exposure to a traumatic event, some develop symptoms sufficient to meet the diagnostic criteria for PTSD. Table 1.1 describes the criteria used to assess PTSD as defined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).² The NSDUH MHSS used these DSM-IV criteria to assess whether adults had PTSD in the past year.

Two prior nationally representative surveys have provided DSM-IV–based PTSD estimates for U.S. civilian, noninstitutionalized adults. The National Comorbidity Survey Replication (NCS-R) estimates of lifetime and past year PTSD were 6.8 and 3.5 percent, respectively,^3,4 whereas the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) estimated 6.4 percent of the population meeting lifetime DSM-IV criteria.⁵ Moreover, one meta-analysis conducted from a systematic review that combined data from 35 longitudinal clinical or communitybased, nonnationally representative samples determined that 28.8 percent (range: 3.1 to 87.5 percent) of adults exposed to one or more PTEs met criteria for PTSD 1 month after trauma exposure.⁶ Estimates conditioned on those exposed to one or more PTEs are higher than the prevalence estimates among all adults. In addition, this study found that 17.0 percent of the original pooled sample continued to meet criteria for PTSD 12 months after exposure (range: 0.6 to 43.8 percent).⁶

PTSD estimates have been shown to differ by gender, age, race/ethnicity, and chronic medical conditions.^{3,4,7,8,9,10,11} Various studies also have identified significant associations between posttraumatic stress, including PTSD, and other mental and substance use disorders. For example, NESARC showed significant correlations between lifetime subclinical PTSD (as defined by exposure to a PTE where the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others [Criterion A1], at least one symptom of re-experiencing [Criterion B], at least three avoidance or numbing symptoms [Criterion C], and at least two symptoms of increased arousal [Criterion D], with the disturbance lasting at least a month [Criterion E]) and mood, substance use, and other anxiety disorders, as well as suicide attempts.⁵ NESARC and the Collaborative Psychiatric Epidemiology Surveys found significant correlations between lifetime PTSD and all mood, substance use, and other anxiety disorders examined;^5,9 NCS-R found these associations with past year PTSD as well.⁴ Significant associations were found between PTSD and attention-deficit hyperactivity disorder,¹² conduct disorder (with lifetime PTSD¹³ but not past year PTSD),⁴ alcohol dependence,^14,15,16 cannabis use,¹⁷ and suicidality.^5,18

Although these prior nationally representative surveys provide some information about correlates of PTE exposure and posttraumatic stress, these surveys are now more than a decade old. This report presents correlates of PTE exposure and posttraumatic stress, including PTSD, from a recent, nationally representative sample of U.S. civilian, noninstitutionalized adults from the 2008-2012 NSDUH MHSS. Specifically, this report examines demographic and socioeconomic characteristics, physical health conditions, and mental health and substance use correlates of lifetime PTE exposure and posttraumatic stress. To account for variation attributable to differences in exposure to one or more PTEs and to elucidate factors associated with the development of posttraumatic stress after exposure, analyses focused on past year posttraumatic stress not only among all adults but also among a subset of adults exposed to one or more lifetime PTEs.

The remainder of this report is organized into three sections. Section 2 describes the MHSS clinical study, assessment of exposure to lifetime PTEs and posttraumatic stress, and data analysis methods. Section 3 reports associations between exposure to one or more PTEs or posttraumatic stress with demographic and socioeconomic, physical health, and mental health and substance use indicators. Section 4 presents a discussion of the findings, including public health implications.

2. Methods

The National Survey on Drug Use and Health (NSDUH) is an annual, national face-to-face survey of the civilian, noninstitutionalized population aged 12 or older conducted in the 50 states and the District of Columbia, sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA). NSDUH is designed to provide national and state-level substance use and mental health estimates. The NSDUH questionnaire is administered using computer-assisted interviewing methods. From 2008 to 2012, a subsample of adult NSDUH respondents was selected to participate in the Mental Health Surveillance Study (MHSS) clinical study, which consisted of a telephone interview that included clinical assessments of the presence of selected mental disorders. One of the disorders assessed was posttraumatic stress disorder (PTSD). To help determine whether a respondent had PTSD, the respondent was asked questions about lifetime exposure to one or more potentially traumatic events (PTEs) and associated mental health symptoms. This report examines whether demographic, socioeconomic, and co-occurring physical health conditions differ among those with versus without exposure to lifetime PTEs and among those with versus without various measures of posttraumatic stress. In addition, the report compares the prevalence of mental health and substance use indicators by whether each adult reported lifetime exposure to PTEs and whether each adult reported various measures of posttraumatic stress. The latter analyses also are conducted among adults with lifetime exposure to one or more PTEs only to account for differential exposure to lifetime PTEs and to study potential correlates of traumatic stress development after exposure.

2.1 NSDUH and MHSS Clinical Interview Sampling and Weighting Methods

The MHSS clinical sample was selected from all adult NSDUH respondents who completed the interview in English from 2008 to 2012. Of the approximately 45,000 adults who completed the NSDUH interview annually from 2008 to 2012, approximately 44,000 respondents completed the interview in English. Adult respondents were selected for the MHSS clinical interview using a sampling algorithm. During the 5-year MHSS clinical study, approximately 8,600 respondents were selected to participate in the clinical interview, with 83.7 percent agreeing to participate,^a and 78.3 percent of those who had originally agreed to participate completing the interview. The final overall weighted response rate taking these two stages of nonresponse into account was 64.6 percent. A total of 5,653 respondents completed the MHSS clinical interview and were included in these analyses.^b

Analysis weights were created for the MHSS clinical sample. These weights adjusted the adult NSDUH main interview respondent analysis weights to account for the exclusion of respondents completing the Spanish version of the NSDUH interview, as well as for MHSS clinical interview nonresponse. The weights were also post-stratified to NSDUH control totals, and a final annual scaling factor was applied to the weights for all cases across the years 2008 to 2012 to account for the different annual clinical sample designs and sample sizes. These final weights were used to compute the disorder-level estimates and standard errors presented in this report. Further details on MHSS clinical study recruitment, sampling, and weighting procedures for 2008 to 2012 can be found in the MHSS operations report and the MHSS design and estimation report.^19,20

2.2 Data Collection

Clinical interviewers contacted MHSS clinical study participants by telephone, ensured the confidentiality and privacy of responses, obtained informed consent, and conducted interviews. The mean length of the interview was 72 minutes, with a median of 60 minutes. These interviews were conducted within 4 weeks of completing the NSDUH interview. Respondents were provided a $30 incentive for participating in the NSDUH interview and an additional $30 for the MHSS clinical interview. The Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I)²¹ was administered over the telephone by master's- or doctorallevel clinically trained interviewers who had undergone extensive training with clinical supervisors and the developer of the SCID. To ensure that the highest standards of quality were met, all SCID interviews were reviewed by one or more doctoral-level clinical supervisors who were trained by and received ongoing consultation from SAMHSA and National Institute of Mental Health staff, as well as the SCID developer. Further details on MHSS training procedures for 2008 to 2012 and details about the SCID administration and quality control in the MHSS clinical study are available as part of several methodological reports.^13,20

The clinical interview consisted of a modified version of the SCID-I. The MHSS version of the SCID was modified in order to assess mental and substance use disorders experienced in the 12 months before the interview, based on diagnostic criteria from the DSM-IV-TR.²² As a semistructured clinical interview, the SCID contains structured, standardized questions that are read verbatim and sequentially. The MHSS clinical study interviewers also were instructed to ask unstructured follow-up questions tailored to each respondent. Interviewers coded the presence or absence of each symptom or disorder based on their clinical judgment and respondents' answers to both the structured and the unstructured questions.

Considered the "gold standard" in psychiatric assessment,^23,24 the SCID has demonstrated good reliability^25,26,27 and validity.^{28,29,30,31,32,33} The SCID has also been widely used as a clinical validation tool for other instruments used in studies such as the National Comorbidity Survey Replication (NCS-R),³⁴ the National Survey of American Life,³⁵ and the NSDUH substance use disorders reappraisal study.³⁶ Studies that compared telephone with face-to-face administration of the SCID have also found good reliability and validity for the telephone-administered SCID.^{37,38,39,40,41,42,43}

PTSD was one of the disorders assessed in the MHSS clinical study (see Appendix A for the SCID module used in the MHSS). The PTSD module assessed past year PTSD. To screen into this module, respondents had to affirm that they had been exposed to one or more PTEs in their lifetime (DSM-IV PTSD Criterion A1) and then affirm at least one of the DSM-IV Criterion B questions: (1) had re-experienced the traumatic event through recurrent nightmares, flashbacks, or intrusive thoughts; or (2) had gotten very upset when recalling the traumatic event (see Figure 2.1). In this report, these Criterion B symptoms are sometimes referred to as experiencing "recurrent upsetting memories or flashbacks" to facilitate clarity of reporting.

Figure 2.1 Assessment of Lifetime Exposure to One or More PTEs and Posttraumatic Stress in the MHSS Clinical Study

D

DSM-IV = fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (see endnote 2 for reference); MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms. NOTE: Specific diagnostic criteria are described in Table 1.1. * Respondents meeting past year Criteria A1 and A2 affirmed the lifetime Criterion A1 question (lifetime exposure to one or more PTEs) and either of the screener questions assessing two of the more prominent lifetime Criterion B symptoms (traumatic experience keeps coming back in recurrent flashbacks, or thoughts were hard to get rid of OR respondent becomes very upset when in a situation that is reminiscent of the traumatic experience).

2.3 Measures

The past year PTSD module included items to assess whether the traumatic event(s) in question met the DSM-IV PTSD Criteria A1 and A2 definitions of a traumatic event (i.e., that the event involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others that was accompanied by a response that involved intense fear, helplessness, or horror). If both Criteria A1 and A2 were met, the respondent was then assessed for symptoms to meet Criterion B, which included having at least one of five re-experiencing symptoms in the past year. If Criteria A and B were met, respondents were assessed for meeting Criterion C, with at least three of seven avoidance symptoms experienced in the past year. If Criteria A, B, and C were met, respondents were assessed for Criterion D, which included reporting at least two of five hyperarousal symptoms in the past year. Adults meeting Criteria A through D then were asked questions assessing Criterion E, which included experiencing the symptoms for at least 1 month in the past year, and Criterion F, symptoms causing clinically significant impairment in the past year. Respondents affirming all PTSD Criteria A through F met the definition of past year PTSD. Respondents affirming all PTSD Criteria A and B as well as endorsing at least one symptom from Criterion C have been classified as having past year posttraumatic stress symptoms (PTSS) for the purpose of this study. Adults with PTSD were also included in the past year PTSS group.

For this analysis, four nonmutually exclusive measures of traumatic event exposure and posttraumatic stress were examined. These measures included the following:

1. Lifetime exposure to one or more PTEs (lifetime DSM-IV PTSD Criterion A1). This outcome will be called "exposure to one or more PTEs" throughout the remainder of this report. The current study estimates that 40.8 percent of adults aged 18 or older have had lifetime exposure to one or more PTEs.
2. Lifetime exposure to one or more PTEs followed by recurrent upsetting memories or flashbacks (lifetime DSM-IV PTSD Criterion A1 and one of the assessed lifetime Criterion B symptoms).
3. Past year PTSS (including PTSD) (past year DSM-IV PTSD Criteria A1, A2, and B, plus at least one symptom from Criterion C). This outcome will be called "past year PTSS" henceforth. The current study estimates that just over 2 percent (2.1 percent) of adults have past year PTSS and that 5.2 percent of adults with one or more lifetime PTEs have past year PTSS.
4. Past year PTSD (past year DSM-IV PTSD Criteria A1, A2, B, C, D, E, and F). The current study estimates that 0.7 percent of adults have past year PTSD and that, among adults with one or more lifetime PTEs, 1.8 percent have past year PTSD.

These measures were selected to compare correlates of lifetime exposure to one or more PTEs and past year posttraumatic stress with those reported in prior studies such as those conducted using the NCS-R and the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) data.^4,5 The correlates of lifetime exposure to one or more PTEs can be compared with those studied using NESARC data because NESARC used a similar criterion to define PTE exposure (lifetime PTSD Criterion A1). However, the MHSS SCID was modified in such a way that it does not enable comparisons with correlates of lifetime PTSS or PTSD found in other studies. Instead, the lifetime exposure to one or more PTEs followed by recurrent upsetting memories or flashbacks variable serves as a proxy for having at least some level of lifetime posttraumatic stress after PTE exposure. The definition of past year PTSS was created to be similar to the "subclinical" PTSD variable used by NESARC, with the acknowledgment that the definitions are not the same. Unlike NESARC, the skip pattern in the MHSS directed the interviewer out of the PTSD module as soon as a respondent did not fully meet one of the PTSD criteria (e.g., Criterion D questions were not asked unless Criteria A and B were met and at least three of the Criterion C questions were affirmed; Criterion E questions were not asked unless Criteria A, B, and C were met and at least two Criterion D questions were affirmed). Therefore, the presence of Criterion D symptoms is assessed only among people meeting Criteria A, B, and C; those who failed to meet earlier criteria would have exited the module. The MHSS used DSM-IV criteria to define past year PTSD, similar to the criteria used to define past year PTSD in the NCS-R, although the MHSS also included screener questions to enter the past year PTSD assessment module.

The potential correlates of exposure to one or more PTEs and posttraumatic stress were selected based on a review of the literature and data available in NSDUH. Variables selected included demographic and socioeconomic characteristics, self-reported receipt of a physical or mental health diagnosis, and mental health and substance use indicators.

2.4 Data Analysis

Comparisons were made between adults with lifetime exposure to one or more PTEs and adults with posttraumatic stress for this report using SCID data from 5,653 MHSS clinical interviews conducted between 2008 and 2012. Because the annual sample sizes in the clinical study are small, annual estimates for each comparison are not feasible; therefore, estimates for each comparison are based on the combined 5-year MHSS clinical sample. Data on the characteristics (such as demographic, socioeconomic, and health conditions) of the MHSS respondents were obtained as part of the NSDUH main interviews for each of these respondents. These data were used to

• describe adults with lifetime exposure to one or more PTEs (e.g., by looking at the distribution of characteristics such as age, gender, etc., among adults with lifetime exposure to one or more PTEs and comparing with characteristics among the total adult population), lifetime exposure to one or more PTEs followed by upsetting memories and flashbacks, past year PTSS, and past year PTSD (Section 3.1);
• compare the prevalence estimates of lifetime exposure to one or more PTEs, lifetime exposure to one or more PTEs followed by upsetting memories and flashbacks, past year PTSS, and past year PTSD between levels of these characteristics to understand characteristics of individuals with versus without lifetime exposure to PTEs and with versus without each posttraumatic stress measure (Section 3.2); and
• examine the prevalence of mental health and substance use issues by lifetime exposure to one or more PTEs and posttraumatic stress variables (including PTSD) (Section 3.3).

It should be noted that Section 3.2 describes the prevalence of lifetime exposure to one or more PTEs among all adults and describes the prevalence of various postraumatic stress measures among all adults and among adults who had lifetime exposure to one or more PTEs by subpopulations of interest. Likewise, Section 3.3 describes the prevalence of mental health and substance use issues by lifetime exposure to one or more PTEs and posttraumatic stress measures among all adults and among adults with lifetime exposure to one or more PTEs. These separate sets of analyses enable the examination of factors associated with posttraumatic stress measures among all adults and factors associated with posttraumatic stress among adults with lifetime exposure to one or more PTEs.

Estimates, along with the associated standard errors (SEs) via a Taylor series linearization approach, were computed using SUDAAN^® to account for analysis weights and complex survey design.^c,19,20,44 The SEs were used to identify unreliable estimates and test for the statistical significance of differences between estimates across each correlate level.^d,45 An alpha level of 0.05 was set as an indicator of statistical significance. A simple Bonferroni adjustment was applied when more than two levels were compared, by taking the standard .05 p value and dividing it by the number of pairwise comparisons.^e,46

The proportion of missing data and the imputation strategy differed for each variable. The age variable collected from the NSDUH main interview has no missing data. For some of the variables from the NSDUH main interview included in these analyses (e.g., gender, race/ethnicity), missing values were imputed using the predictive mean neighborhood method.^f,47,48 For poverty status, also taken from the main NSDUH interview, all the respondents aged 18 to 22 who lived in college dormitories were assigned missing values. Respondents with missing data on a particular comorbid mental or physical condition were excluded from that particular bivariate analysis; missing data were less than 1 percent for each of these variables. For variables collected from the MHSS clinical interview, missing values were not imputed. If one or more variables needed to make a combined exposure to PTE or posttraumatic stress variable were missing, the variable itself was coded as missing. The proportion of missing values for the exposure to PTE and posttraumatic stress variables is small (i.e., less than 1 percent).

3. Results

This section presents estimated numbers and percentages of civilian, noninstitutionalized adults living in the United States who have been exposed to one or more lifetime potentially traumatic events (PTEs) and who have experienced posttraumatic stress using data from the 2008-2012 Mental Health Surveillance Study clinical study. First, overall estimates of exposure to PTEs and posttraumatic stress, including past year posttraumatic stress symptoms (PTSS) and posttraumatic stress disorder (PTSD), are presented, followed by characteristics of those with exposure to one or more lifetime PTEs and those with posttraumatic stress among all adults and among adults with lifetime exposure to one or more PTEs. Next, significant differences in exposure to PTEs and posttraumatic stress by demographic and socioeconomic variables among all adults are described, followed by differences in posttraumatic stress by these variables among adults with exposure to one or more lifetime PTEs. Finally, differences in estimates of substance use, mental health, and physical health indicators among adults with versus without lifetime exposure to one or more PTEs, one or more PTEs followed by recurrent upsetting memories or flashbacks, past year PTSS, and past year PTSD are presented and discussed. Significant differences between those with and without past year PTSS and with and without past year PTSD are also reported among the sample of adults with exposure to one or more lifetime PTEs, to identify factors that may contribute to the development of posttraumatic stress after exposure to a PTE. Any differences referenced in the text represent statistically significant differences at the p < .05 level of significance.

3.1 Comparisons of Demographic and Socioeconomic Characteristics of Adults Overall with Adults Who Had Exposure to One or More Lifetime PTEs and Posttraumatic Stress

Table 3.1 presents demographic and socioeconomic characteristics of all adults alongside those of adults with exposure to one or more lifetime PTEs, adults with lifetime PTEs followed by upsetting memories or flashbacks,^g adults with past year PTSS,^h and adults with past year PTSD. P values for differences in these characteristics between all adults and adults with each PTE exposure/posttraumatic stress measure are included in Appendix Table B1.

Table 3.1 Distribution of Demographic and Socioeconomic Characteristics among All Adults Aged 18 or Older, by Lifetime Exposure to One or More PTEs and Posttraumatic Stress: MHSS Clinical Study, 2008-2012

Characteristic	All Adults (n = 5,653)	Adults with Lifetime Exposure to One or More PTEs1 (n = 2,679)	Adults with Lifetime Exposure to One or More PTEs Followed by Recurrent Upsetting Memories or Flashbacks2 (n = 1,382)	Adults with Past Year PTSS3 (n = 376)	Adults with Past Year PTSD (n = 116)
	Percentage (SE)	Percentage (SE)	Percentage (SE)	Percentage (SE)	Percentage (SE)
MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms; SE = standard error. NOTE: Standard errors of weighted percentages have been computed with the WTADJX procedure of SUDAAN® 11.0.1 (see endnote 45 for reference), recognizing that the clinical sample weights were calibrated annually to estimated totals computed from a larger NSDUH sample of adults. * No estimate reported due to low precision. An estimate is considered to have low precision if prevalence < 0.00005 or 0.99995, sample size < 100, effective sample size < 68, or relative standard error of the natural log of the prevalence > 0.175. 1 Respondents reported exposure to one or more PTEs in their lifetime. 2 Respondents reported exposure to one or more PTEs in their lifetime, which was followed by nightmares, flashbacks, thoughts they could not get rid of, or being upset when in a situation that reminded them of the event. 3 Based on definitions found in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; see endnote 2 for reference), respondents met DSM-IV PTSD Criterion A (lifetime exposure to one or more PTEs and response that involved intense fear, helplessness, or horror), met Criterion B in the past year (at least one symptom of persistent re-experiencing the traumatic event), and affirmed at least one symptom of persistent avoidance from Criterion C in the past year. Those classified as having past year PTSD also were classified as having past year PTSS. 4 The other employment category includes students, people keeping house or caring for children full time, retired or disabled people, or other people not in the labor force. 5 Estimates are based on a definition of poverty level that incorporates information on family income, size, and composition and is calculated as a percentage of the U.S. Census Bureau's poverty thresholds. Respondents aged 18 to 22 who were living in a college dormitory were excluded. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH Main Study and Clinical Sample, 2008-2012.
Age
18-25	14.7 (<0.1)	11.5 (0.8)	12.2 (1.3)	16.4 (2.6)	13.2 (3.1)
26-49	42.4 (<0.1)	43.3 (1.3)	43.2 (2.5)	53.8 (4.0)	*    (*)
50 or Older	42.8 (<0.1)	45.2 (1.4)	44.6 (2.6)	29.9 (4.1)	*    (*)
Gender
Male	48.2 (<0.1)	49.8 (1.4)	39.7 (2.6)	33.0 (4.3)	*    (*)
Female	51.8 (<0.1)	50.2 (1.4)	60.3 (2.6)	67.0 (4.3)	*    (*)
Hispanic/Latino Origin and Race
Not Hispanic/Latino White	67.1 (<0.1)	72.3 (1.5)	73.6 (2.5)	70.2 (4.3)	*    (*)
Not Hispanic/Latino Black/African    American	11.5 (<0.1)	11.4 (1.0)	11.2 (1.6)	9.3 (2.1)	4.6 (2.2)
Not Hispanic/Latino Other	7.0 (<0.1)	4.6 (0.7)	4.8 (1.0)	8.6 (2.3)	*    (*)
Hispanic/Latino	14.4 (<0.1)	11.7 (1.2)	10.5 (2.0)	*    (*)	*    (*)
Education
Less than High School	13.1 (0.9)	13.6 (1.3)	13.9 (2.1)	22.7 (4.2)	*    (*)
High School Graduate	29.4 (1.3)	28.5 (1.9)	26.4 (2.7)	27.5 (3.8)	*    (*)
Some College	27.4 (1.2)	30.0 (1.8)	29.2 (2.4)	30.6 (4.2)	*    (*)
College Graduate	30.2 (1.2)	27.9 (1.6)	30.6 (2.9)	19.2 (3.2)	15.9 (4.1)
Current Employment
Full Time	51.1 (1.1)	52.0 (1.8)	43.6 (2.5)	34.9 (4.5)	*    (*)
Part Time	13.2 (0.8)	12.6 (1.2)	14.3 (2.2)	15.8 (3.1)	*    (*)
Unemployed	6.5 (0.7)	6.4 (1.0)	9.6 (2.2)	7.9 (1.8)	4.1 (1.7)
Other4	29.2 (1.0)	29.0 (1.5)	32.5 (2.4)	41.5 (5.0)	*    (*)
Poverty Level5
Less than 100%	12.4 (0.9)	12.9 (1.4)	16.2 (2.2)	20.2 (2.7)	27.4 (5.3)
100%-199%	19.0 (0.9)	18.2 (1.5)	18.0 (1.9)	23.8 (3.5)	*    (*)
200% or More	68.6 (1.2)	68.9 (1.8)	65.7 (2.5)	56.0 (4.3)	*    (*)
Family Income
Less than $20,000	15.7 (1.0)	16.4 (1.5)	19.4 (2.3)	29.2 (3.4)	*    (*)
$20,000-$49,999	33.3 (1.1)	33.4 (1.7)	36.8 (2.4)	36.1 (4.2)	*    (*)
$50,000-$74,999	17.8 (0.9)	18.5 (1.3)	17.6 (1.9)	14.7 (3.6)	*    (*)
$75,000 or More	33.3 (1.3)	31.8 (1.9)	26.2 (2.5)	20.1 (3.6)	*    (*)
Marital Status
Married	53.8 (1.4)	52.7 (2.0)	49.4 (2.9)	54.3 (3.8)	*    (*)
Widowed	4.5 (0.6)	6.9 (1.1)	8.3 (2.2)	2.4 (1.5)	*    (*)
Divorced or Separated	16.1 (1.2)	17.8 (1.6)	18.1 (2.0)	17.0 (2.6)	*    (*)
Never Married	25.6 (0.7)	22.6 (1.4)	24.2 (2.5)	26.3 (3.4)	*    (*)
Veteran Status
Yes	12.0 (0.9)	17.8 (1.9)	16.6 (2.5)	19.0 (3.9)	*    (*)
No	88.0 (0.9)	82.2 (1.9)	83.4 (2.5)	81.0 (3.9)	*    (*)

Table 3.2 Lifetime Exposure to One or More PTEs and Posttraumatic Stress among Adults Aged 18 or Older, by Demographic and Socioeconomic Characteristics: MHSS Clinical Study, 2008-2012 (n = 5,653)

Characteristic	Lifetime Exposure to One or More PTEs1	Lifetime Exposure to One or More PTEs Followed by Recurrent Upsetting Memories or Flashbacks2	Past Year PTSS3	Past Year PTSD
	Percentage (SE)	Percentage (SE)	Percentage (SE)	Percentage (SE)
MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms; SE = standard error. NOTE: Standard errors of weighted percentages have been computed with the WTADJX procedure of SUDAAN® 11.0.1 (see endnote 44 for reference), recognizing that the clinical sample weights were calibrated annually to estimated totals computed from a larger NSDUH sample of adults. Exposure to one or more PTEs and posttraumatic stress variables are not mutually exclusive. NOTE: Definitions for standard terms are included in the endnotes. * No estimate reported due to low precision. An estimate is considered to have low precision if prevalence < 0.00005 or 0.99995, sample size < 100, effective sample size < 68, or relative standard error of the natural log of the prevalence > 0.175. 1 Respondents reported exposure to one or more PTEs in their lifetime. 2 Respondents reported exposure to one or more PTEs in their lifetime, which was followed by nightmares, flashbacks, thoughts they could not get rid of, or being upset when in a situation that reminded them of the event. 3 Based on definitions found in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; see endnote 2 for reference), respondents met PTSD Criterion A (traumatic event exposure and response that involved intense fear, helplessness, or horror), met Criterion B in the past year (at least one symptom of persistent re-experiencing the traumatic event), and affirmed at least one symptom of persistent avoidance from Criterion C in the past year. Those classified as having past year PTSD also were classified as having past year PTSS. 4 The other employment category includes students, people keeping house or caring for children full time, retired or disabled people, or other people not in the labor force. 5 Estimates are based on a definition of poverty level that incorporates information on family income, size, and composition and is calculated as a percentage of the U.S. Census Bureau's poverty thresholds. Respondents aged 18 to 22 who were living in a college dormitory were excluded. 6 Respondents reported that a doctor or other medical professional had told them that they had each condition in their lifetime (ever). 7 Other health conditions examined included cirrhosis, hepatitis, HIV/AIDS, lung cancer, pancreatitis, stroke, and tuberculosis, but estimates were suppressed, so they are not presented. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH Main Study and Clinical Sample, 2008-2012.
Total	40.8 (1.4)	15.8 (0.9)	2.1 (0.2)	0.7 (0.1)
Age
18-25	32.0 (2.3)	13.1 (1.4)	2.3 (0.4)	0.7 (0.2)
26-49	41.6 (1.7)	16.0 (1.1)	2.7 (0.3)	0.9 (0.2)
50 or Older	42.9 (2.3)	16.5 (1.6)	1.5 (0.3)	0.6 (0.2)
Gender
Male	42.1 (1.8)	13.1 (1.2)	1.4 (0.2)	0.6 (0.2)
Female	39.6 (1.7)	18.3 (1.3)	2.7 (0.3)	0.8 (0.1)
Hispanic/Latino Origin and Race
Not Hispanic/Latino White	43.9 (1.5)	17.4 (1.1)	2.2 (0.2)	0.9 (0.1)
Not Hispanic/Latino Black/African    American	40.3 (4.1)	15.2 (2.3)	1.7 (0.4)	0.3 (0.1)
Not Hispanic/Latino Other	26.8 (4.0)	10.8 (2.3)	2.5 (0.7)	1.0 (0.5)
Hispanic/Latino	33.3 (3.9)	11.5 (2.4)	1.7 (0.7)	0.4 (0.3)
Education
Less than High School	42.3 (3.8)	16.7 (2.7)	3.6 (0.9)	1.3 (0.4)
High School Graduate	39.7 (2.3)	14.3 (1.5)	2.0 (0.3)	0.9 (0.2)
Some College	44.6 (2.4)	16.9 (1.6)	2.4 (0.4)	0.7 (0.2)
College Graduate	37.7 (2.1)	15.9 (1.7)	1.3 (0.3)	0.4 (0.1)
Current Employment
Full Time	41.5 (1.9)	13.5 (1.0)	1.4 (0.2)	0.4 (0.1)
Part Time	38.9 (3.2)	17.1 (2.9)	2.5 (0.6)	0.8 (0.3)
Unemployed	40.1 (4.9)	23.1 (4.8)	2.5 (0.6)	0.5 (0.2)
Other4	40.6 (2.5)	17.7 (1.8)	3.0 (0.5)	1.4 (0.2)
Poverty Level5
Less than 100%	42.4 (4.0)	20.7 (2.6)	3.4 (0.5)	1.6 (0.4)
100%-199%	39.4 (3.1)	15.1 (1.6)	2.6 (0.4)	0.8 (0.2)
200% or More	41.2 (1.6)	15.2 (1.1)	1.7 (0.2)	0.6 (0.1)
Family Income
Less than $20,000	42.6 (3.5)	19.5 (2.1)	3.9 (0.6)	1.7 (0.4)
$20,000-$49,999	40.9 (2.5)	17.5 (1.6)	2.3 (0.3)	0.7 (0.2)
$50,000-$74,999	42.6 (2.4)	15.7 (1.8)	1.7 (0.5)	0.4 (0.2)
$75,000 or More	38.9 (2.0)	12.4 (1.2)	1.3 (0.3)	0.5 (0.2)
Marital Status
Married	39.8 (1.9)	14.5 (1.2)	2.1 (0.3)	0.8 (0.1)
Widowed	*    (*)	*    (*)	1.1 (0.7)	*  (*)
Divorced or Separated	45.1 (3.3)	17.9 (2.3)	2.2 (0.4)	0.8 (0.2)
Never Married	36.3 (2.1)	14.9 (1.6)	2.2 (0.3)	0.7 (0.2)
Veteran Status
Yes	60.3 (4.8)	22.1 (3.2)	3.4 (0.9)	1.6 (0.6)
No	38.1 (1.4)	15.0 (0.9)	1.9 (0.2)	0.6 (0.1)
Health Conditions (Lifetime)6,7
Physical Health Condition
Asthma	56.2 (3.3)	23.4 (2.5)	3.5 (0.7)	1.6 (0.5)
No Asthma	39.0 (1.4)	14.9 (0.9)	1.9 (0.2)	0.6 (0.1)
Bronchitis	46.5 (3.6)	22.5 (2.7)	3.6 (0.7)	1.5 (0.5)
No Bronchitis	40.3 (1.4)	15.1 (0.9)	1.9 (0.2)	0.7 (0.1)
Diabetes	44.8 (4.6)	25.5 (4.2)	2.7 (0.8)	1.6 (0.6)
No Diabetes	40.6 (1.4)	14.9 (0.9)	2.1 (0.2)	0.6 (0.1)
Heart Disease	*    (*)	*    (*)	2.7 (1.0)	1.1 (0.7)
No Heart Disease	39.9 (1.4)	15.3 (0.9)	2.1 (0.2)	0.7 (0.1)
High Blood Pressure	47.4 (3.2)	21.1 (2.3)	2.4 (0.5)	1.3 (0.3)
No High Blood Pressure	38.9 (1.4)	14.3 (0.9)	2.0 (0.2)	0.5 (0.1)
Pneumonia	50.3 (5.0)	22.1 (3.3)	2.2 (0.6)	1.0 (0.5)
No Pneumonia	40.4 (1.4)	15.5 (0.9)	2.1 (0.2)	0.7 (0.1)
Sexually Transmitted Disease	*    (*)	33.0 (5.2)	4.3 (1.0)	1.1 (0.7)
No Sexually Transmitted Disease	40.4 (1.4)	15.2 (0.9)	2.0 (0.2)	0.7 (0.1)
Sinusitis	52.6 (3.4)	23.2 (2.7)	2.9 (0.5)	1.2 (0.3)
No Sinusitis	39.5 (1.4)	15.0 (0.9)	2.0 (0.2)	0.7 (0.1)
Sleep Apnea	50.9 (5.4)	23.4 (4.2)	4.1 (0.9)	2.7 (0.8)
No Sleep Apnea	40.4 (1.4)	15.5 (0.9)	2.0 (0.2)	0.6 (0.1)
Tinnitus	*    (*)	*    (*)	4.7 (1.4)	2.9 (1.1)
No Tinnitus	40.7 (1.4)	15.7 (0.9)	2.1 (0.2)	0.7 (0.1)
Ulcer	58.3 (5.0)	35.8 (5.0)	4.6 (1.2)	1.1 (0.5)
No Ulcer	40.4 (1.4)	15.2 (0.9)	2.0 (0.2)	0.7 (0.1)
History of Anxiety or Depression
Anxiety	51.9 (3.3)	30.3 (2.6)	9.2 (1.1)	4.2 (0.7)
No Anxiety	39.9 (1.5)	14.5 (0.9)	1.4 (0.2)	0.4 (0.1)
Depression	59.6 (2.5)	36.0 (2.5)	8.9 (1.0)	3.8 (0.6)
No Depression	38.2 (1.5)	12.9 (0.9)	1.1 (0.1)	0.3 (0.1)

Lifetime Exposure to One or More PTEs Followed by Recurrent Upsetting Memories or Flashbacks

Estimated percentages of adults with lifetime exposure to PTEs followed by recurrent upsetting memories or flashbacks were higher among female than male adults (18.3 vs. 13.1 percent, respectively), among veterans than nonveterans (22.1 vs. 15.0 percent), and among adults with family incomes of less than $20,000 versus $75,000 or higher (19.5 vs. 12.4 percent; Table 3.2). Lifetime exposure to one or more PTEs followed by recurrent upsetting memories or flashbacks did not vary by age group, race/ethnicity, education, employment, poverty status, or marital status.⁵⁰ P values for each comparison are listed in Appendix Table B2.

Past Year PTSS

Among all adults, the past year estimate of PTSSⁱ (which, as previously mentioned, includes adults with PTSD) was higher for adults aged 26 to 49 versus those aged 50 or older (2.7 vs. 1.5 percent) and for females than males (2.7 vs. 1.4 percent; Table 3.2). Adults with current "other" employment status (which includes individuals on disability)⁵¹ had higher percentages of past year PTSS than adults working full time (3.0 vs. 1.4 percent). Adults at less than 100 percent of the federal poverty level and adults with family incomes of less than $20,000 per year, respectively, had higher past year PTSS estimates than adults at 200 percent or greater of the poverty level and adults with family incomes of $50,000-$74,999 and $75,000 or higher. P values for each comparison are listed in Appendix Table B2.

Among adults with lifetime exposure to one or more PTEs, significant differences in past year PTSS by age, gender, employment status, and income (but not living below the federal poverty level) followed patterns similar to those found among all adults. The past year estimated percentage of adults with PTSS was higher for adults aged 18 to 25 and adults aged 26 to 49 than for adults aged 50 or older (7.3 and 6.4 vs. 3.5 percent, respectively; Table 3.3). Females had a higher percentage of past year PTSS than males (6.9 vs. 3.5 percent, respectively). Adults with "other" employment status had higher estimates of past year PTSS than adults working full time (7.5 vs. 3.5 percent). Adults with family incomes of less than $20,000 per year had higher past year estimates of PTSS than adults with family incomes of $75,000 or higher (9.3 vs. 3.2 percent).⁵² P values for each nonsuppressed comparison are listed in Appendix Table B3.

Table 3.3 Past Year PTSS and PTSD among Adults Aged 18 or Older with Lifetime Exposure to One or More PTEs,¹ by Demographic and Socioeconomic Characteristics: MHSS Clinical Study, 2008-2012 (n = 2,679)

Characteristic	Past Year PTSS2	Past Year PTSD
	Percentage (SE)	Percentage (SE)
MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms; SE = standard error. NOTE: Standard errors of weighted percentages have been computed with the WTADJX procedure of SUDAAN® 11.0.1 (see endnote 44 for reference), recognizing that the clinical sample weights were calibrated annually to estimated totals computed from a larger NSDUH sample of adults. PTSS and PTSD are not mutually exclusive. NOTE: Definitions for standard terms are included in the endnotes. * No estimate reported due to low precision. An estimate is considered to have low precision if prevalence < 0.00005 or 0.99995, sample size < 100, effective sample size < 68, or relative standard error of the natural log of the prevalence > 0.175. 1 Respondents reported exposure to one or more PTEs in their lifetime. 2 Based on definitions found in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; see endnote 2 for reference), respondents met DSM-IV PTSD Criterion A (lifetime exposure to one or more PTEs and response that involved intense fear, helplessness, or horror), met Criterion B in the past year (at least one symptom of persistent re-experiencing the traumatic event), and affirmed at least one symptom of persistent avoidance from Criterion C in the past year. Those classified as having past year PTSD also were classified as having past year PTSS. 3 The other employment category includes students, people keeping house or caring for children full time, retired or disabled people, or other people not in the labor force. 4 Estimates are based on a definition of poverty level that incorporates information on family income, size, and composition and is calculated as a percentage of the U.S. Census Bureau's poverty thresholds. Respondents aged 18 to 22 who were living in a college dormitory were excluded. 5 Respondents reported that a doctor or other medical professional had told them that they had each condition in their lifetime (ever). 6 Other health conditions examined included cirrhosis, hepatitis, HIV/AIDS, lung cancer, pancreatitis, stroke, and tuberculosis, but estimates were suppressed, so they are not presented. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH Main Study and Clinical Sample, 2008-2012.
Total	5.2 (0.5)	1.8 (0.2)
Age
18-25	7.3 (1.3)	2.1 (0.5)
26-49	6.4 (0.7)	2.2 (0.4)
50 or Older	3.5 (0.7)	1.4 (0.4)
Gender
Male	3.5 (0.6)	1.6 (0.4)
Female	6.9 (0.7)	2.1 (0.4)
Hispanic/Latino Origin and Race
Not Hispanic/Latino White	5.1 (0.5)	2.0 (0.3)
Not Hispanic/Latino Black/African American	4.2 (1.0)	0.7 (0.4)
Not Hispanic/Latino Other	9.5 (3.0)	3.6 (1.7)
Hispanic/Latino	5.2 (2.0)	*  (*)
Education
Less than High School	8.6 (2.1)	3.0 (0.9)
High School Graduate	5.0 (0.8)	2.3 (0.6)
Some College	5.4 (0.8)	1.6 (0.5)
College Graduate	3.5 (0.7)	1.0 (0.3)
Current Employment
Full Time	3.5 (0.5)	1.0 (0.3)
Part Time	6.6 (1.5)	2.1 (0.9)
Unemployed	6.3 (1.6)	1.2 (0.5)
Other3	7.5 (1.2)	3.4 (0.7)
Poverty Level4
Less than 100%	8.0 (1.6)	3.8 (1.0)
100%-199%	6.8 (1.2)	2.1 (0.6)
200% or More	4.2 (0.6)	1.4 (0.3)
Family Income
Less than $20,000	9.3 (1.6)	4.1 (1.0)
$20,000-$49,999	5.7 (0.8)	1.8 (0.4)
$50,000-$74,999	4.1 (1.2)	1.0 (0.4)
$75,000 or More	3.2 (0.7)	1.2 (0.4)
Marital Status
Married	5.4 (0.7)	1.9 (0.4)
Widowed	*    (*)	*  (*)
Divorced or Separated	5.0 (0.9)	1.8 (0.5)
Never Married	6.0 (1.0)	1.8 (0.5)
Veteran Status
Yes	5.7 (1.5)	2.7 (1.0)
No	5.1 (0.5)	1.6 (0.2)
Health Conditions (Lifetime)5,6
Physical Health Condition
Asthma	6.2 (1.3)	2.8 (0.9)
No Asthma	5.0 (0.5)	1.6 (0.2)
Bronchitis	7.9 (1.6)	3.1 (1.1)
No Bronchitis	4.8 (0.5)	1.6 (0.2)
Diabetes	6.1 (1.8)	3.7 (1.4)
No Diabetes	5.1 (0.5)	1.6 (0.2)
Heart Disease	4.7 (1.7)	2.0 (1.1)
No Heart Disease	5.3 (0.5)	1.8 (0.2)
High Blood Pressure	5.1 (1.0)	2.9 (0.7)
No High Blood Pressure	5.3 (0.5)	1.4 (0.2)
Pneumonia	4.5 (1.2)	1.9 (0.9)
No Pneumonia	5.3 (0.5)	1.8 (0.3)
Sexually Transmitted Disease	7.9 (1.9)	2.1 (1.3)
No Sexually Transmitted Disease	5.1 (0.5)	1.8 (0.3)
Sinusitis	5.6 (1.1)	2.4 (0.7)
No Sinusitis	5.1 (0.5)	1.7 (0.3)
Sleep Apnea	8.3 (1.8)	5.4 (1.6)
No Sleep Apnea	5.0 (0.5)	1.6 (0.3)
Tinnitus	*  (*)	*  (*)
No Tinnitus	5.1 (0.5)	1.7 (0.3)
Ulcer	8.0 (2.3)	1.8 (0.8)
No Ulcer	5.1 (0.5)	1.8 (0.3)
History of Anxiety or Depression
Anxiety	17.8 (2.1)	8.1 (1.4)
No Anxiety	3.6 (0.5)	1.1 (0.2)
Depression	15.2 (1.8)	6.5 (1.0)
No Depression	2.9 (0.4)	0.8 (0.2)

Table 3.4 Substance Use, Mental Health, and Physical Health Indicators among Adults Aged 18 or Older, by Lifetime Exposure to One or More PTEs and Posttraumatic Stress: MHSS Clinical Study, 2008-2012 (n = 5,653)

Substance Use, Mental Health, and Physical Health Indicators	Lifetime Exposure to One or More PTEs1		Lifetime Exposure to One or More PTEs Followed by Recurrent Upsetting Memories or Flashbacks2		Past Year PTSS3		Past Year PTSD
	Yes Percentage (SE)	No Percentage (SE)	Yes Percentage (SE)	No Percentage (SE)	Yes Percentage (SE)	No Percentage (SE)	Yes Percentage (SE)	No Percentage (SE)
MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms; SE = standard error. NOTE: Standard errors of weighted percentages have been computed with the WTADJX procedure of SUDAAN® 11.0.1 (see endnote 44 for reference), recognizing that the clinical sample weights were calibrated annually to estimated totals computed from a larger NSDUH sample of adults. Exposure to one or more PTEs and posttraumatic stress variables are not mutually exclusive. NOTE: Definitions for standard terms are included in the endnotes. a Significant difference at p < .05 level in substance use/mental health/physical health estimate for "yes" as compared with the "no" level of exposure to one or more PTEs/posttraumatic stress variables. An estimate is considered to have low precision if prevalence < 0.00005 or 0.99995, sample size < 100, effective sample size < 68, or relative standard error of the natural log of the prevalence > 0.175. 1 Respondents reported exposure to one or more PTEs in their lifetime. 2 Respondents reported exposure to one or more PTEs in their lifetime, which was followed by nightmares, flashbacks, thoughts they could not get rid of, or being upset when in a situation that reminded them of the event. 3 Based on definitions found in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; see endnote 2 for reference), respondents met PTSD Criterion A (lifetime exposure to one or more PTEs and response that involved intense fear, helplessness, or horror), met Criterion B in the past year (at least one symptom of persistent re-experiencing the traumatic event), and affirmed at least one symptom of persistent avoidance from Criterion C in the past year. Those classified as having past year PTSD also were classified as having past year PTSS. 4 The "any mental illness" estimate in NSDUH is calculated using a calibration model that includes PTSD as a mental disorder in the gold standard definition. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH Main Study and Clinical Sample, 2008-2012.
Substance Use in Lifetime
Used Illicit Drugs	60.0a (1.8)	45.9  (1.5)	59.4a (2.7)	50.3  (1.4)	70.3a (5.1)	51.3  (1.4)	*     (*)	51.7  (1.3)
Used Illicit Drugs Other Than Marijuana	38.4a (1.8)	26.7  (1.4)	36.2a (2.2)	30.6  (1.4)	53.4a (4.6)	31.0  (1.2)	*     (*)	31.4  (1.2)
Substance Use in the Past Year
Used Illicit Drugs	18.8a (1.2)	13.3  (0.9)	17.0  (1.5)	15.3  (0.9)	21.9  (3.6)	15.5  (0.7)	12.5  (3.5)	15.6  (0.7)
Used Illicit Drugs Other Than Marijuana	9.0  (0.8)	6.7  (0.9)	9.7  (1.1)	7.3  (0.7)	13.1a (2.7)	7.6  (0.6)	10.4  (3.3)	7.7  (0.6)
Used Marijuana	14.7a (1.1)	10.1  (0.6)	12.7  (1.4)	11.9  (0.6)	19.8a (3.6)	11.9  (0.6)	12.1  (3.5)	12.0  (0.5)
Nonmedical Use of Psychotherapeutics	7.0a (0.8)	4.9  (0.6)	7.0  (0.8)	5.6  (0.6)	11.3a (2.6)	5.7  (0.5)	8.2  (3.0)	5.8  (0.5)
Used a Tobacco Product	42.2a (1.9)	30.6  (1.4)	42.2a (2.5)	34.1  (1.2)	54.3a (4.6)	35.0  (1.0)	*     (*)	35.1  (1.0)
Alcohol Dependence or Abuse	8.5  (0.8)	6.7  (0.8)	8.4  (1.0)	7.3  (0.7)	17.7a (2.8)	7.2  (0.6)	*     (*)	7.3  (0.6)
Illicit Drug Dependence or Abuse	3.3  (0.4)	2.2  (0.5)	4.4a (0.7)	2.3  (0.4)	9.2a (2.5)	2.5  (0.4)	*     (*)	2.6  (0.4)
Any Substance Use Disorder	10.1a (0.8)	7.7  (0.8)	10.9  (1.1)	8.3  (0.7)	21.5a (3.3)	8.5  (0.6)	*     (*)	8.6  (0.6)
Received Substance Use Treatment	1.9a (0.3)	1.0  (0.2)	2.3a (0.5)	1.2  (0.2)	5.7a (1.6)	1.3  (0.2)	*     (*)	1.3  (0.2)
Alcohol Use in the Past Month
Binge Drinking	29.6a (1.8)	23.4  (1.3)	26.1  (2.8)	26.0  (1.2)	28.0  (4.1)	26.0  (1.1)	*     (*)	25.9  (1.1)
Heavy Drinking	9.5a (1.1)	6.5  (0.9)	7.3  (1.5)	7.8  (0.9)	10.4  (3.5)	7.7  (0.8)	*     (*)	7.7  (0.8)
Mental Health Measures in the Past Year
Any Mental Illness4	23.2a (1.0)	14.3  (0.6)	33.6a (2.1)	15.1  (0.4)	75.6a (4.4)	16.7  (0.3)	*     (*)	17.5  (0.3)
Serious Mental Illness	6.1a (0.4)	2.4  (0.2)	11.2a (0.9)	2.5  (0.2)	37.1a (4.4)	3.2  (0.2)	*     (*)	3.5  (0.2)
Serious Psychological Distress	14.4a (0.7)	8.1  (0.4)	22.8a (1.6)	8.5  (0.3)	58.5a (4.5)	9.7  (0.2)	*     (*)	10.3  (0.2)
Major Depressive Episode	10.1a (0.5)	4.3  (0.2)	16.0a (1.2)	5.0  (0.2)	49.9a (4.7)	5.7  (0.1)	*     (*)	6.3  (0.1)
Suicidal Thoughts	4.4a (0.3)	3.1  (0.2)	7.8a (0.8)	2.9  (0.1)	21.8a (3.4)	3.3  (0.1)	*     (*)	3.5  (0.1)
Received Mental Health Treatment/    Counseling	17.8a (1.1)	10.4  (0.8)	26.9a (2.3)	11.0  (0.6)	57.1a (3.9)	12.4  (0.6)	*     (*)	12.8  (0.6)
History of Anxiety	11.0a (0.8)	7.0  (0.8)	16.5a (1.6)	7.2  (0.6)	37.6a (3.9)	8.0  (0.5)	*     (*)	8.3  (0.5)
History of Depression	18.7a (1.1)	8.8  (0.7)	29.2a (2.4)	9.8  (0.6)	53.9a (4.2)	11.8  (0.6)	*     (*)	12.3  (0.6)
Physical Health Condition
Asthma	15.3a (1.3)	8.3  (0.8)	16.5a (1.6)	10.2  (0.9)	18.5a (3.2)	11.0  (0.8)	*     (*)	11.1  (0.8)
Bronchitis	11.9  (1.1)	9.5  (1.0)	14.9a (1.7)	9.7  (0.8)	18.1a (3.2)	10.3  (0.8)	*     (*)	10.4  (0.8)
Cirrhosis of the Liver	0.1  (<0.1)	0.5  (0.3)	0.1  (0.1)	0.4  (0.2)	0.1  (0.1)	0.3  (0.2)	*     (*)	0.3  (0.2)
Diabetes	10.1  (1.2)	8.7  (1.2)	14.9a (2.4)	8.2  (0.9)	11.8  (3.3)	9.2  (0.9)	*     (*)	9.2  (0.9)
Heart Disease	8.0a (1.3)	4.0  (0.7)	9.0  (2.2)	5.0  (0.7)	7.2  (2.3)	5.6  (0.7)	*     (*)	5.7  (0.7)
Hepatitis	1.4  (0.3)	0.9  (0.2)	1.5  (0.6)	1.0  (0.2)	1.6  (1.1)	1.1  (0.2)	*     (*)	1.1  (0.2)
High Blood Pressure	27.9a (1.8)	21.4  (1.4)	31.8a (3.1)	22.4  (1.1)	26.8  (4.2)	23.8  (1.1)	*     (*)	23.8  (1.1)
HIV/AIDS	0.1  (0.1)	0.3  (0.3)	0.2  (0.2)	0.2  (0.2)	0.1  (0.1)	0.2  (0.2)	*     (*)	0.2  (0.2)
Lung Cancer	0.5  (0.3)	0.8  (0.4)	0.8  (0.6)	0.7  (0.3)	*     (*)	0.7  (0.3)	*     (*)	0.7  (0.3)
Pancreatitis	0.7  (0.2)	0.8  (0.5)	0.8  (0.3)	0.7  (0.3)	1.0  (0.5)	0.7  (0.3)	*     (*)	0.7  (0.3)
Pneumonia	6.6a (0.7)	4.6  (0.7)	7.5  (1.1)	5.0  (0.6)	5.7  (1.4)	5.4  (0.5)	*     (*)	5.4  (0.5)
Sexually Transmitted Disease	5.3a (0.7)	3.0  (0.6)	8.2a (1.2)	3.1  (0.5)	8.0a (1.6)	3.8  (0.5)	*     (*)	3.9  (0.4)
Sinusitis	14.5a (1.2)	9.1  (0.8)	16.5a (1.8)	10.3  (0.8)	15.4  (2.7)	11.1  (0.7)	*     (*)	11.2  (0.7)
Sleep Apnea	6.6a (0.9)	4.4  (0.7)	7.9  (1.5)	4.9  (0.6)	10.4a (2.0)	5.2  (0.5)	*     (*)	5.2  (0.5)
Stroke	2.6  (0.8)	1.2  (0.4)	2.1  (0.8)	1.7  (0.5)	1.2  (0.6)	1.8  (0.4)	*     (*)	1.8  (0.4)
Tinnitus	2.7  (0.6)	1.7  (0.5)	3.4  (0.9)	1.9  (0.4)	4.7  (1.4)	2.1  (0.3)	8.3a (3.0)	2.1  (0.3)
Tuberculosis	0.5  (0.2)	0.6  (0.3)	0.3  (0.1)	0.6  (0.2)	0.4  (0.3)	0.5  (0.2)	*     (*)	0.5  (0.2)
Ulcer	4.8a (0.6)	2.4  (0.4)	7.6a (1.3)	2.6  (0.3)	7.4a (1.8)	3.3  (0.3)	4.9  (2.0)	3.4  (0.3)

Figure 3.1 Key Substance Use Indicators among Adults Aged 18 or Older, by Lifetime Exposure to One or More PTEs: MHSS Clinical Study, 2008-2012 (n = 5,653)

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MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event. * Differences between the lifetime exposure to one or more PTEs and no lifetime exposure to PTEs groups were significant at the p < .05 level. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH Main Study and Clinical Sample, 2008-2012.

Figure 3.2 Mental Health Indicators among Adults Aged 18 or Older, by Lifetime Exposure to One or More PTEs: MHSS Clinical Study, 2008-2012 (n = 5,653)

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MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event. * Differences between the lifetime exposure to one or more PTEs and no lifetime exposure to PTEs groups were significant at the p < .05 level. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH Main Study and Clinical Sample, 2008-2012.

Table 3.5 Substance Use, Mental Health, and Physical Health Indicators among Adults Aged 18 or Older with Lifetime Exposure to One or More PTEs,¹ by Past Year PTSS and PTSD: MHSS Clinical Study, 2008-2012 (n = 2,679)

Substance Use, Mental Health, and Physical Health Indicators	Past Year PTSS2		Past Year PTSD
	Yes Percentage (SE)	No Percentage (SE)	Yes Percentage (SE)	No Percentage (SE)
MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms; SE = standard error. NOTE: Standard errors of weighted percentages have been computed with the WTADJX procedure of SUDAAN® 11.0.1 (see endnote 44 for reference), recognizing that the clinical sample weights were calibrated annually to estimated totals computed from a larger NSDUH sample of adults. PTSS and PTSD are not mutually exclusive. NOTE: Definitions for standard terms are included in the endnotes. a Significant difference at p < .05 level in substance use/mental health estimate for "yes" as compared with the "no" level of past year PTSS or of past year PTSD. * No estimate reported due to low precision. An estimate is considered to have low precision if prevalence < 0.00005 or 0.99995, sample size < 100, effective sample size < 68, or relative standard error of the natural log of the prevalence > 0.175. 1 Respondents reported exposure to one or more PTEs in their lifetime. 2 Based on definitions found in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; see endnote 2 for reference), respondents met DSM-IV PTSD Criterion A (exposure to one or more PTEs and response that involved intense fear, helplessness, or horror), met Criterion B in the past year (at least one symptom of persistent re-experiencing the traumatic event), and affirmed at least one symptom of persistent avoidance from Criterion C in the past year. Those classified as having past year PTSD also were classified as having past year PTSS. 3 The "any mental illness" estimate in NSDUH is calculated using a calibration model that includes PTSD as a mental disorder in the gold standard definition. 4 Due to unknown values for this variable, n = 2,664. 5 Due to unknown values for this variable, n = 2,677. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH Main Study and Clinical Sample, 2008-2012.
Substance Use in Lifetime
Used Illicit Drugs	70.3  (5.1)	59.8  (1.9)	*  (*)	60.3  (1.8)
Used Illicit Drugs Other Than    Marijuana	53.4a (4.6)	37.7  (2.0)	*  (*)	38.3  (1.9)
Substance Use in the Past Year
Used Illicit Drugs	21.9  (3.3)	18.9  (1.3)	12.5  (3.4)	19.2  (1.2)
Used Illicit Drugs Other Than    Marijuana	13.1  (2.5)	8.9  (0.8)	10.4  (3.2)	9.1  (0.8)
Used Marijuana	19.8  (3.2)	14.6  (1.2)	12.1  (3.4)	14.9  (1.1)
Nonmedical Use of    Psychotherapeutics	11.3  (2.4)	6.8  (0.8)	8.2  (3.0)	7.0  (0.8)
Used a Tobacco Product	54.3a (4.1)	41.7  (1.9)	*  (*)	41.9  (1.9)
Alcohol Dependence or Abuse	17.7a (2.9)	8.1  (0.8)	*  (*)	8.4  (0.8)
Illicit Drug Dependence or Abuse	9.2a (2.3)	3.0  (0.4)	*  (*)	3.3  (0.4)
Any Substance Use Disorder	21.5a (3.2)	9.6  (0.8)	*  (*)	10.0  (0.8)
Received Substance Use Treatment	5.7a (1.6)	1.7  (0.3)	*  (*)	1.8  (0.3)
Alcohol Use in the Past Month
Binge Drinking	28.0  (3.9)	30.0  (1.7)	*  (*)	29.8  (1.7)
Heavy Drinking	10.4  (2.9)	9.5  (1.2)	*  (*)	9.5  (1.2)
Mental Health Measures in the Past Year
Any Mental Illness3	75.6a (4.4)	20.4  (0.8)	*  (*)	22.3  (0.9)
Serious Mental Illness	37.1a (4.0)	4.4  (0.4)	*  (*)	5.2  (0.4)
Serious Psychological Distress	58.5a (4.1)	12.1  (0.6)	*  (*)	13.6  (0.6)
Major Depressive Episode4	49.9a (4.7)	8.0  (0.5)	*  (*)	9.2  (0.4)
Suicidal Thoughts	21.8a (3.0)	3.5  (0.3)	21.8a (4.9)	4.1  (0.3)
Received Mental Health Treatment/ Counseling5	57.1a (3.8)	15.4  (1.1)	*  (*)	16.4  (1.1)
History of Anxiety	37.6a (3.6)	9.5  (0.8)	*  (*)	10.3  (0.8)
History of Depression	53.9a (4.0)	16.6  (1.1)	*  (*)	17.6  (1.1)
Physical Health Condition
Asthma	18.5  (3.2)	15.3  (1.4)	*  (*)	15.3  (1.3)
Bronchitis	18.1  (3.1)	11.6  (1.1)	*  (*)	11.8  (1.1)
Cirrhosis of the Liver	0.1  (0.1)	0.1  (0.1)	*  (*)	0.1  (0.1)
Diabetes	11.8  (3.3)	10.0  (1.2)	*  (*)	9.9  (1.2)
Heart Disease	7.2  (2.3)	8.2  (1.3)	*  (*)	8.1  (1.3)
Hepatitis	1.6  (1.1)	1.4  (0.4)	*  (*)	1.4  (0.4)
High Blood Pressure	26.8  (3.9)	27.6  (1.8)	*  (*)	27.3  (1.8)
HIV/AIDS	0.1  (0.1)	0.1  (0.1)	*  (*)	0.1  (0.1)
Lung Cancer	*  (*)	0.5  (0.3)	*  (*)	0.5  (0.3)
Pancreatitis	1.0  (0.5)	0.6  (0.2)	*  (*)	0.6  (0.2)
Pneumonia	5.7  (1.4)	6.7  (0.7)	*  (*)	6.6  (0.7)
Sexually Transmitted Disease	8.0  (1.6)	5.2  (0.7)	*  (*)	5.3  (0.7)
Sinusitis	15.4  (2.7)	14.4  (1.3)	*  (*)	14.3  (1.3)
Sleep Apnea	10.4  (2.0)	6.3  (0.8)	*  (*)	6.2  (0.8)
Stroke	1.2  (0.6)	2.6  (0.8)	*  (*)	2.6  (0.7)
Tinnitus	4.7  (1.4)	2.6  (0.7)	8.3  (3.0)	2.6  (0.6)
Tuberculosis	0.4  (0.3)	0.5  (0.2)	*  (*)	0.5  (0.2)
Ulcer	7.4  (1.8)	4.7  (0.6)	4.9  (2.0)	4.8  (0.6)

Figure 3.3 Key Substance Use Indicators among Adults Aged 18 or Older with Lifetime Exposure to One or More PTEs, by Past Year PTSS: MHSS Clinical Study, 2008-2012 (n = 2,679)

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MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms. * Differences between the past year PTSS and no past year PTSS groups were significant at the p < .05 level. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH Main Study and Clinical Sample, 2008-2012.

Figure 3.4 Mental Health Indicators among Adults Aged 18 or Older with Lifetime Exposure to One or More PTEs, by Past Year PTSS: MHSS Clinical Study, 2008-2012 (n = 2,679)

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MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms. * Differences between the past year PTSS and no past year PTSS groups were significant at the p < .05 level. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH Main Study and Clinical Sample, 2008-2012.

Figure 3.5 Lifetime Physical Health Conditions among Adults Aged 18 or Older That Significantly (p < .05) Differ, by Lifetime Exposure to One or More PTEs: MHSS Clinical Study, 2008-2012 (n = 5,653)

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MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event. NOTE: Other physical health conditions assessed in NSDUH that were not significantly associated with lifetime exposure to one or more PTEs included bronchitis, cirrhosis of the liver, diabetes, stroke, tinnitus, and tuberculosis. * Differences between the lifetime exposure to one or more PTEs and no lifetime exposure to PTEs groups were significant at the p < .05 level. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH Main Study and Clinical Sample, 2008-2012.

4. Discussion

4.1 Summary of Results

This study provides the most recent investigation of characteristics of people with lifetime exposure to one or more potentially traumatic events (PTEs) and posttraumatic stress using nationally representative data. Furthermore, this study examines the extent of mental health issues and substance use measures by each of the four trauma-related measures among U.S. adults aged 18 or older and among those exposed to lifetime exposure to one or more PTEs.

Several correlates of lifetime exposure to one or more PTEs and posttraumatic stress variables were identified (see Table 4.1 for a summary of demographic and socioeconomic correlates of each of these variables). For example, lifetime exposure to one or more PTEs was associated with increased age, not Hispanic/Latino white race/ethnicity (compared with not Hispanic/Latino "other"), and veteran status, but not with gender and other demographic and socioeconomic variables studied. In addition, past year posttraumatic stress symptoms (PTSS) estimates (which also included those with past year posttraumatic stress disorder [PTSD]) were higher among adults aged 26 to 49 than among adults aged 50 or older, among females as compared with males, among those with "other" employment (which includes disability, as compared with those who were employed full time or unemployed), and for lower family income both among all adults and among adults with lifetime exposure to one or more PTEs. Among all adults, past year PTSD was associated with not Hispanic/Latino white race/ethnicity (compared with not Hispanic/Latino black/African American), "other" employment status (which includes disability, as compared with those who were employed full time), and lower family income, but not with gender, age, veteran status, or the other demographic or socioeconomic variables studied.

Table 4.2 Summary of Significant Differences in Percentages of Substance Use and Mental Health Measures, by Lifetime Exposure to One or More PTEs and Posttraumatic Stress, among All Adults Aged 18 or Older and among Adults Aged 18 or Older with Lifetime Exposure to One or More PTEs: MHSS Clinical Study, 2008-2012

Substance Use and Mental Health Measures	Among All Adults (n = 5,653)				Among Adults with Lifetime Exposure to One or More PTEs (n = 2,679)
	Lifetime Exposure to One or More PTEs1	Lifetime Exposure to One or More PTEs Followed by Upsetting Memories or Flashbacks2	Past Year PTSS3	Past Year PTSD	Past Year PTSS3	Past Year PTSD
MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms. NOTE: Standard errors of weighted percentages have been computed with the WTADJX procedure of SUDAAN® 11.0.1 (see endnote 44 for reference), recognizing that the clinical sample weights were calibrated annually to estimated totals computed from a larger NSDUH sample of adults. NOTE: Definitions for standard terms are included in the endnotes. + Significant difference at p < .05 level of significance. * No estimate reported due to low precision. An estimate is considered to have low precision if prevalence < 0.00005 or 0.99995, sample size < 100, effective sample size < 68, or relative standard error of the natural log of the prevalence > 0.175. 1 Respondents reported exposure to one or more PTEs in their lifetime. 2 Respondents reported exposure to one or more PTEs in their lifetime, which was followed by nightmares, flashbacks, thoughts they could not get rid of, or being upset when in a situation that reminded them of the event. 3 Based on definitions found in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; see endnote 2 for reference), respondents met PTSD Criterion A (exposure to one or more PTEs and response that involved intense fear, helplessness, or horror), met Criterion B in the past year (at least one symptom of persistent re-experiencing the traumatic event), and affirmed at least one symptom of persistent avoidance from Criterion C in the past year. Those classified as having past year PTSD also were classified as having past year PTSS. 4 The "any mental illness" estimate in NSDUH is calculated using a calibration model that includes PTSD as a mental disorder in the gold standard definition. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH Main Study and Clinical Sample, 2008-2012.
Substance Use in Lifetime
Used Illicit Drugs	+	+	+	*		*
Used Illicit Drugs Other Than    Marijuana	+	+	+	*	+	*
Substance Use in the Past Year
Used Illicit Drugs	+
Used Illicit Drugs Other Than    Marijuana			+
Used Marijuana	+		+
Nonmedical Use of    Psychotherapeutics			+
Used a Tobacco Product	+	+	+	*	+	*
Alcohol Dependence or Abuse			+	*	+	*
Illicit Drug Dependence or    Abuse		+	+	*	+	*
Any Substance Use Disorder	+		+	*	+	*
Received Substance Use    Treatment	+	+	+	*	+	*
Alcohol Use in the Past Month
Binge Drinking	+			*		*
Heavy Drinking	+			*		*
Mental Health Measures in the Past Year
Any Mental Illness4	+	+	+	*	+	*
Serious Mental Illness	+	+	+	*	+	*
Serious Psychological Distress	+	+	+	*	+	*
Major Depressive Episode	+	+	+	*	+	*
Suicidal Thoughts	+	+	+	*	+	+
Received Mental Health Treatment/Counseling	+	+	+	*	+	*
History of Anxiety	+	+	+	*	+	*
History of Depression	+	+	+	*	+	*
Physical Health Condition
Asthma	+	+	+	*		*
Bronchitis		+	+	*		*
Cirrhosis of the Liver				*		*
Diabetes		+		*		*
Heart Disease	+			*		*
Hepatitis				*		*
High Blood Pressure	+	+		*		*
HIV/AIDS				*		*
Lung Cancer				*	*	*
Pancreatitis				*		*
Pneumonia	+			*		*
Sexually Transmitted Disease	+	+	+	*		*
Sinusitis	+	+		*		*
Sleep Apnea	+		+	*		*
Stroke				*		*
Tinnitus				*		*
Tuberculosis				*		*
Ulcer	+	+	+			*

Author Affiliations

Jonaki Bose, Larke N. Huang, and Sarra L. Hedden are with the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, Rockville, MD. Valerie L. Forman-Hoffman, Kathryn R. Batts, Cristie Glasheen, Erica Hirsch, and Rhonda S. Karg are with RTI International (a registered trademark and a trade name of Research Triangle Institute), Research Triangle Park, NC.

Acknowledgments of Reviewers

The authors would like to thank Kathryn Piscopo of the Center for Behavioral Health Statistics and Quality and Kelley Smith of the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, for reviewing previous drafts of this Data Review.

Endnotes

Footnotes

Appendix A: Posttraumatic Stress Module from the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I)

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Appendix B: Significance Tables

Table B.1 Tests of Differences of Percentages of Demographic and Socioeconomic Characteristics among All Adults Aged 18 or Older vs. Subgroups of Those with Lifetime Exposure to One or More PTEs or Posttraumatic Stress Measures: P Values for Table 3.1, MHSS Clinical Study, 2008-2012

Characteristic	Adults with Lifetime Exposure to One or More PTEs1 (n = 2,679) vs. All Adults (n = 5,653)	Adults with Lifetime Exposure to One or More PTEs1 Followed by Recurrent Upsetting Memories or Flashbacks2 (n = 1,382) vs. All Adults (n = 5,653)	Adults with Past Year PTSS3 (n = 376) vs. All Adults (n = 5,653)	Adults with Past Year PTSD (n = 116) vs. All Adults (n = 5,653)
MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms. NOTE: Standard errors of weighted percentages have been computed with the WTADJX procedure of SUDAAN® 11.0.1 (see endnote 44 for reference), recognizing that the clinical sample weights were calibrated annually to estimated totals computed from a larger NSDUH sample of adults. NOTE: To account for making pairwise comparisons, a difference is considered significant when p < .05 divided by the number of pairwise comparisons. * No estimate reported due to low precision. An estimate is considered to have low precision if prevalence < 0.00005 or  0.99995, sample size < 100, effective sample size < 68, or relative standard error of the natural log of the prevalence > 0.175. 1 Respondents reported exposure to one or more PTEs in their lifetime. 2 Based on definitions found in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; see endnote 2 for reference), respondents met DSM-IV PTSD Criterion A (PTE exposure and response that involved intense fear, helplessness, or horror), met Criterion B in the past year (at least one symptom of persistent re-experiencing the traumatic event), and affirmed at least one symptom of persistent avoidance from Criterion C in the past year. Those classified as having PTSD also were classified as having PTSS. 3 Respondents reported that a doctor or other medical professional had told them that they had each condition in their lifetime (ever). 4 The other employment category includes students, people keeping house or caring for children full time, retired or disabled people, or other people not in the labor force. 5 Estimates are based on a definition of poverty level that incorporates information on family income, size, and composition and is calculated as a percentage of the U.S. Census Bureau's poverty thresholds. Respondents aged 18 to 22 who were living in a college dormitory were excluded. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH Main Study and Clinical Sample, 2008-2012.
Age
18-25	0.0002	0.0479	0.5293	0.6166
26-49	0.4814	0.7528	0.0052	*
50 or Older	0.0960	0.5011	0.0022	*
Gender
Male	0.2570	0.0019	0.0006	*
Female	0.2570	0.0019	0.0006	*
Hispanic/Latino Origin and Race
Not Hispanic/Latino White	0.0005	0.0106	0.4675	*
Not Hispanic/Latino Black/African American	0.9090	0.8317	0.2996	0.0021
Not Hispanic/Latino Other	0.0006	0.0257	0.4982	*
Hispanic/Latino	0.0310	0.0509	*	*
Education
Less than High School	0.7481	0.7312	0.0268	*
High School Graduate	0.7096	0.3220	0.6420	*
Some College	0.2242	0.5137	0.4586	*
College Graduate	0.2606	0.8998	0.0016	0.0011
Current Employment
Full Time	0.6474	0.0070	0.0008	*
Part Time	0.6724	0.6321	0.4135	*
Unemployed	0.9391	0.1957	0.4977	0.2025
Other4	0.8925	0.2123	0.0177	*
Poverty Level5
Less than 100%	0.7988	0.1078	0.0074	0.0060
100%-199%	0.6788	0.6593	0.1782	*
200% or More	0.8909	0.3076	0.0062	*
Family Income
Less than $20,000	0.6991	0.1578	0.0003	*
$20,000-$49,999	0.9526	0.1884	0.5175	*
$50,000-$74,999	0.6612	0.9410	0.4133	*
$75,000 or More	0.5176	0.0159	0.0008	*
Marital Status
Married	0.6301	0.1752	0.9076	*
Widowed	0.0636	0.0981	0.1899	*
Divorced or Separated	0.3858	0.3952	0.7520	*
Never Married	0.0741	0.5952	0.8422	*
Veteran Status
Yes	0.0063	0.0929	0.0818	*
No	0.0063	0.0929	0.0818	*

Table B.2 Tests of Differences of Percentages of Lifetime Exposure to One or More PTEs and Posttraumatic Stress among Adults Aged 18 or Older, by Demographic and Socioeconomic Characteristics: P Values for Table 3.2, MHSS Clinical Study, 2008-2012 (n = 5,653)

Characteristic	Lifetime Exposure to One or More PTEs1	Lifetime Exposure to One or More PTEs Followed by Recurrent Upsetting Memories or Flashbacks2	Past Year PTSS3	Past Year PTSD
MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms. NOTE: Standard errors of weighted percentages have been computed with the WTADJX procedure of SUDAAN® 11.0.1 (see endnote 44 for reference), recognizing that the clinical sample weights were calibrated annually to estimated totals computed from a larger NSDUH sample of adults. Exposure to one or more PTEs and posttraumatic stress variables are not mutually exclusive. NOTE: To account for making pairwise comparisons, a difference is considered significant when p < .05 divided by the number of pairwise comparisons. * No estimate reported due to low precision. An estimate is considered to have low precision if prevalence < 0.00005 or  0.99995, sample size < 100, effective sample size < 68, or relative standard error of the natural log of the prevalence > 0.175. 1 Respondents reported exposure to one or more PTEs in their lifetime. 2 Respondents reported exposure to one or more PTEs in their lifetime, which was followed by nightmares, flashbacks, thoughts they could not get rid of, or being upset when in a situation that reminded them of the event. 3 Based on definitions found in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; see endnote 2 for reference), respondents met PTSD Criterion A (PTE exposure and response that involved intense fear, helplessness, or horror), met Criterion B in the past year (at least one symptom of persistent re-experiencing the traumatic event), and affirmed at least one symptom of persistent avoidance from Criterion C in the past year. Those classified as having PTSD also were classified as having PTSS. 4 The other employment category includes students, people keeping house or caring for children full time, retired or disabled people, or other people not in the labor force. 5 Estimates are based on a definition of poverty level that incorporates information on family income, size, and composition and is calculated as a percentage of the U.S. Census Bureau's poverty thresholds. Respondents aged 18 to 22 who were living in a college dormitory were excluded. 6 Respondents reported that a doctor or other medical professional had told them that they had each condition in their lifetime (ever). Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH Main Study and Clinical Sample, 2008-2012.
Age
18-25 vs. 26-49	0.0011	0.1022	0.4897	0.3199
18-25 vs. 50 or Older	0.0011	0.1092	0.0612	0.8295
26-49 vs. 50 or Older	0.6521	0.8013	0.0026	0.2428
Gender
Male vs. Female	0.3180	0.0031	0.0006	0.4171
Hispanic/Latino Origin and Race
Not Hispanic/Latino White vs. Not Hispanic/Latino Black/African American	0.4018	0.4057	0.2324	0.0041
Not Hispanic/Latino White vs. Not Hispanic/Latino Other	0.0001	0.0120	0.6412	0.8139
Not Hispanic/Latino White vs. Hispanic/Latino	0.0120	0.0265	0.5063	0.1948
Not Hispanic/Latino Black/African American vs. Not Hispanic/Latino Other	0.0199	0.1782	0.2832	0.1559
Not Hispanic/Latino Black/African American vs. Hispanic/Latino	0.2132	0.2605	0.9457	0.7462
Not Hispanic/Latino Other vs. Hispanic/Latino	0.2509	0.8338	0.4045	0.3118
Education
Less than High School vs. High School Graduate	0.5564	0.4361	0.0759	0.3999
Less than High School vs. Some College	0.6020	0.9394	0.1856	0.2129
Less than High School vs. College Graduate	0.2895	0.8157	0.0132	0.0288
High School Graduate vs. Some College	0.1404	0.2253	0.3936	0.5650
High School Graduate vs. College Graduate	0.5260	0.4619	0.1033	0.0371
Some College vs. College Graduate	0.0323	0.6701	0.0196	0.1405
Current Employment
Full Time vs. Part Time	0.4875	0.2332	0.0738	0.2493
Full Time vs. Unemployed	0.7939	0.0512	0.0896	0.7810
Full Time vs. Other4	0.7614	0.0426	0.0026	0.0005
Part Time vs. Unemployed	0.8354	0.2827	0.9836	0.3674
Part Time vs. Other4	0.6843	0.8468	0.5173	0.1961
Unemployed vs. Other4	0.9370	0.2983	0.5137	0.0043
Poverty Level5
Less than 100% vs. 100%-199%	0.5491	0.0744	0.2667	0.0547
Less than 100% vs. 200% or More	0.7781	0.0553	0.0054	0.0061
100%-199% vs. 200% or More	0.5996	0.9654	0.0460	0.3657
Family Income
Less than $20,000 vs. $20,000-$49,999	0.6933	0.4415	0.0141	0.0184
Less than $20,000 vs. $50,000-$74,999	0.9942	0.1663	0.0043	0.0020
Less than $20,000 vs. $75,000 or More	0.3637	0.0038	0.0000	0.0022
$20,000-$49,999 vs. $50,000-$74,999	0.6204	0.4440	0.3557	0.1847
$20,000-$49,999 vs. $75,000 or More	0.5428	0.0113	0.0164	0.2140
$50,000-$74,999 vs. $75,000 or More	0.2395	0.1414	0.3938	0.8527
Marital Status
Married vs. Widowed	*	*	0.1974	*
Married vs. Divorced or Separated	0.1718	0.2081	0.8116	0.8562
Married vs. Never Married	0.2101	0.8328	0.9178	0.7035
Widowed vs. Divorced or Separated	*	*	0.1739	*
Widowed vs. Never Married	*	*	0.1897	*
Divorced or Separated vs. Never Married	0.0255	0.3092	0.8936	0.6409
Veteran Status
Yes vs. No	0.0000	0.0352	0.0999	0.0836
Health Conditions (Lifetime)6
Physical Health Condition
Asthma vs. No Asthma	0.0000	0.0023	0.0375	0.0713
Bronchitis vs. No Bronchitis	0.1167	0.0094	0.0246	0.1272
Cirrhosis of the Liver vs. No Cirrhosis of the Liver	*	*	*	*
Diabetes vs. No Diabetes	0.3823	0.0153	0.4629	0.1299
Heart Disease vs. No Heart Disease	*	*	0.5317	0.5273
Hepatitis vs. No Hepatitis	*	*	*	*
High Blood Pressure vs. No High Blood Pressure	0.0150	0.0066	0.5061	0.0166
HIV/AIDS vs. No HIV/AIDS	*	*	*	*
Lung Cancer vs. No Lung Cancer	*	*	*	*
Pancreatitis vs. No Pancreatitis	*	*	*	*
Pneumonia vs. No Pneumonia	0.0583	0.0582	0.8473	0.6274
Sexually Transmitted Disease vs. No Sexually Transmitted Disease	*	0.0010	0.0320	0.5763
Sinusitis vs. No Sinusitis	0.0006	0.0048	0.1300	0.1193
Sleep Apnea vs. No Sleep Apnea	0.0632	0.0657	0.0190	0.0072
Stroke vs. No Stroke	*	*	*	*
Tinnitus vs. No Tinnitus	*	*	0.0729	0.0554
Tuberculosis vs. No Tuberculosis	*	*	*	*
Ulcer vs. No Ulcer	0.0007	0.0001	0.0413	0.4752
History of Anxiety or Depression
Anxiety vs. No Anxiety	0.0013	0.0000	0.0000	0.0000
Depression vs. No Depression	0.0000	0.0000	0.0000	0.0000

Table B.3 Tests of Differences of Percentages of Past Year PTSS and PTSD among Adults Aged 18 or Older with Lifetime Exposure to One or More PTEs,¹ by Demographic and Socioeconomic Characteristics: P Values for Table 3.3, MHSS Clinical Study, 2008-2012 (n = 2,679)

Characteristic	Past Year PTSS2	Past Year PTSD
MHSS = Mental Health Surveillance Study; PTE = potentially traumatic event; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms. NOTE: Standard errors of weighted percentages have been computed with the WTADJX procedure of SUDAAN® 11.0.1 (see endnote 44 for reference), recognizing that the clinical sample weights were calibrated annually to estimated totals computed from a larger NSDUH sample of adults. PTSS and PTSD are not mutually exclusive. NOTE: To account for making pairwise comparisons, a difference is considered significant when p < .05 divided by the number of pairwise comparisons. * No estimate reported due to low precision. An estimate is considered to have low precision if prevalence < 0.00005 or  0.99995, sample size < 100, effective sample size < 68, or relative standard error of the natural log of the prevalence > 0.175. 1 Respondents reported exposure to one or more PTEs in their lifetime. 2 Based on definitions found in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; see endnote 2 for reference), respondents met PTSD Criterion A (PTE exposure and response that involved intense fear, helplessness, or horror), met Criterion B in the past year (at least one symptom of persistent re-experiencing the traumatic event), and affirmed at least one symptom of persistent avoidance from Criterion C in the past year. Those classified as having PTSD also were classified as having PTSS. 3 The other employment category includes students, people keeping house or caring for children full time, retired or disabled people, or other people not in the labor force. 4 Estimates are based on a definition of poverty level that incorporates information on family income, size, and composition and is calculated as a percentage of the U.S. Census Bureau's poverty thresholds. Respondents aged 18 to 22 who were living in a college dormitory were excluded. 5 Respondents reported that a doctor or other medical professional had told them that they had each condition in their lifetime (ever). Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH Main Study and Clinical Sample, 2008-2012.
Age
18-25 vs. 26-49	0.5164	0.9099
18-25 vs. 50 or Older	0.0080	0.3233
26-49 vs. 50 or Older	0.0027	0.2204
Gender
Male vs. Female	0.0005	0.3461
Hispanic/Latino Origin and Race
Not Hispanic/Latino White vs. Not Hispanic/Latino Black/African American	0.4402	0.0114
Not Hispanic/Latino White vs. Not Hispanic/Latino Other	0.1463	0.3541
Not Hispanic/Latino White vs. Hispanic/Latino	0.9380	*
Not Hispanic/Latino Black/African American vs. Not Hispanic/Latino Other	0.0953	0.1074
Not Hispanic/Latino Black/African American vs. Hispanic/Latino	0.6426	*
Not Hispanic/Latino Other vs. Hispanic/Latino	0.2339	*
Education
Less than High School vs. High School Graduate	0.1158	0.5002
Less than High School vs. Some College	0.1625	0.1927
Less than High School vs. College Graduate	0.0256	0.0432
High School Graduate vs. Some College	0.7289	0.3923
High School Graduate vs. College Graduate	0.1649	0.0493
Some College vs. College Graduate	0.0842	0.2522
Current Employment
Full Time vs. Part Time	0.0536	0.2120
Full Time vs. Unemployed	0.1043	0.7362
Full Time vs. Other3	0.0033	0.0008
Part Time vs. Unemployed	0.8850	0.3340
Part Time vs. Other3	0.6418	0.2506
Unemployed vs. Other3	0.5475	0.0065
Poverty Level4
Less than 100% vs. 100%-199%	0.5395	0.1275
Less than 100% vs. 200% or More	0.0237	0.0192
100%-199% vs. 200% or More	0.0453	0.3185
Family Income
Less than $20,000 vs. $20,000-$49,999	0.0498	0.0405
Less than $20,000 vs. $50,000-$74,999	0.0100	0.0049
Less than $20,000 vs. $75,000 or More	0.0007	0.0075
$20,000-$49,999 vs. $50,000-$74,999	0.2534	0.1456
$20,000-$49,999 vs. $75,000 or More	0.0197	0.2395
$50,000-$74,999 vs. $75,000 or More	0.5242	0.7286
Marital Status
Married vs. Widowed	*	*
Married vs. Divorced or Separated	0.7465	0.8681
Married vs. Never Married	0.6118	0.9286
Widowed vs. Divorced or Separated	*	*
Widowed vs. Never Married	*	*
Divorced or Separated vs. Never Married	0.4635	0.9458
Veteran Status
Yes vs. No	0.6997	0.2898
Health Conditions (Lifetime)5
Physical Health Condition
Asthma vs. No Asthma	0.3938	0.2256
Bronchitis vs. No Bronchitis	0.0660	0.1908
Cirrhosis of the Liver vs. No Cirrhosis of the Liver	*	*
Diabetes vs. No Diabetes	0.6116	0.1509
Heart Disease vs. No Heart Disease	0.7376	0.8989
Hepatitis vs. No Hepatitis	*	*
High Blood Pressure vs. No High Blood Pressure	0.8607	0.0454
HIV/AIDS vs. No HIV/AIDS	*	*
Lung Cancer vs. No Lung Cancer	*	*
Pancreatitis vs. No Pancreatitis	*	*
Pneumonia vs. No Pneumonia	0.5476	0.9202
Sexually Transmitted Disease vs. No Sexually Transmitted Disease	0.1456	0.8537
Sinusitis vs. No Sinusitis	0.7290	0.3838
Sleep Apnea vs. No Sleep Apnea	0.0745	0.0178
Stroke vs. No Stroke	*	*
Tinnitus vs. No Tinnitus	*	*
Tuberculosis vs. No Tuberculosis	*	*
Ulcer vs. No Ulcer	0.2191	0.9920
History of Anxiety or Depression
Anxiety vs. No Anxiety	0.0000	0.0000
Depression vs. No Depression	0.0000	0.0000

Long Descriptions – Figures

Long Descriptions – Appendix A