April 2016

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

Authors

Valerie L. Forman-Hoffman, Jonaki Bose, Kathryn R. Batts, Cristie Glasheen, Erica Hirsch, Rhonda S. Karg, Larke N. Huang, Sarra L. Hedden


Abstract

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 evaluating associations with mental health and substance use issues. 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.

Adults with exposure to one or more lifetime PTEs were more likely to be older, to be not Hispanic/Latino white, to be veterans, or to have certain health conditions (asthma, high blood pressure, sinusitis, ulcer, anxiety, and depression). Estimates of lifetime and past year illicit drug use were higher among adults who were exposed to one or more PTEs in their lifetime than among those who were unexposed. Past month binge drinking and heavy drinking were also more likely among adults exposed to one or more PTEs in their lifetime than among adults without exposure. Adults exposed to one or more lifetime PTEs were more likely to have mental illness, serious psychological distress, major depressive episodes, and suicidal thoughts in the past year. They were also more likely to have used mental health services. Significant substance use and mental health correlates of PTSS among adults exposed to one or more lifetime PTEs were similar to those identified as significant correlates of exposure to PTEs among all adults.

Information from this report may aid SAMHSA initiatives to address the needs of people with behavioral health problems by identifying potential targets for prevention, treatment, and recovery and resiliency support services for trauma exposure and related sequelae.

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.

Table 1.1 DSM-IV Definition of PTSD
Criterion Definition
DSM-IV = fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (see endnote 2 for reference); PTSD = posttraumatic stress disorder.
A The person has been exposed to a traumatic event in which both of the following were present:
  1. 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.
  2. The person's response involved intense fear, helplessness, or horror.
B The traumatic event is persistently re-experienced in one or more of the following ways:
  1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
  2. Recurrent distressing dreams of the event.
  3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).
  4. Intense psychological distress at exposure to the internal or external cues that symbolize or resemble an aspect of the traumatic event.
  5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C Persistent avoidance of stimuli associated with the trauma and the numbing of general responsiveness (not present before trauma), as indicated by three or more of the following:
  1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma.
  2. Efforts to avoid the activities, places, or people that arouse recollections of the trauma.
  3. Inability to recall an important aspect of the trauma.
  4. Markedly diminished interest or participation in significant activities.
  5. Feelings of detachment or estrangement from others.
  6. Restricted range of affect (e.g., unable to have loving feelings).
  7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).
D Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:
  1. Difficulty falling or staying asleep.
  2. Irritability or outbursts of anger.
  3. Difficulty concentrating.
  4. Hypervigilance.
  5. Exaggerated startle response.
E The duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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 reliability25,26,27 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
Figure 2.1. For long description follow 'D' link at lower right.     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

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 greater than or equal to 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) *    (*)

Compared with all adults, those with lifetime exposure to one or more PTEs are less likely to be in the youngest age category (18-25 years) (e.g., 11.5 percent of adults with a lifetime exposure to one or more PTEs were aged 18-25 years, compared with 14.7 percent of all adults) and more likely to be not Hispanic/Latino white and veterans. Adults with lifetime exposure to one or more PTEs followed by upsetting memories or flashbacks are more likely to be older, female, not Hispanic/Latino white and less likely to be employed full time than all adults. The age distribution of adults with past year PTSS significantly differed from the age distribution among all adults (e.g., adults with past year PTSS were more likely to be aged 26-49 years and less likely to be aged 50 or older than all adults). Adults with past year PTSS also are more likely to live at less than 100 percent of the poverty level and to have family incomes of less than $20,000 per year and less likely to be employed full time and to have family incomes of more than $75,000 per year than all adults.

3.2 Prevalence of Exposure to One or More Lifetime PTEs and Posttraumatic Stress by Demographic and Socioeconomic Characteristics and Physical and Behavioral Health Conditions among Adults

Lifetime Exposure to One or More PTEs

Table 3.2 provides estimates of lifetime PTE exposure and related posttraumatic stress sequelae for all four of the examined outcomes (lifetime exposure to one or more PTEs and each posttraumatic stress measure) for each demographic and socioeconomic variable. P values for each comparison are listed in Appendix Table B2. Estimated percentages of adults with lifetime exposure to one or more PTEs were higher among adults aged 26 to 49 (41.6 percent) and adults aged 50 or older (42.9 percent) than among adults aged 18 to 25 (32.0 percent; Table 3.2). Likewise, higher percentages of not Hispanic/Latino white adults were exposed to a lifetime PTE than not Hispanic/Latino other49 adults (43.9 vs. 26.8 percent), and a higher percentage of veterans were exposed to one or more lifetime PTEs than nonveterans (60.3 vs. 38.1 percent). Lifetime exposure to one or more PTEs did not vary by gender, education, employment, poverty status, family income level, or marital status. The percentage of adults with lifetime exposure to one or more PTEs was significantly higher among adults with the following medical conditions assessed in the MHSS than among their counterparts who did not have these conditions: asthma, high blood pressure, sinusitis, ulcer, anxiety, and depression.

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 greater than or equal to 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 greater than or equal to 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)

Past Year PTSD

Among all adults, the estimated percentage of those with past year PTSD was higher among not Hispanic/Latino white adults than not Hispanic/Latino black/African American adults (0.9 vs. 0.3 percent; Table 3.2). Similar to those with past year PTSS, adults with "other" employment status and adults with family incomes of less than $20,000 had higher past year PTSD estimates than adults who were employed full time or unemployed and those with family incomes of $50,000-$74,999 and $75,000 or higher, respectively. P values for each nonsuppressed comparison are listed in Appendix Table B2.

Significant differences in past year PTSD by employment status and income (but not race/ethnicity) among adults with lifetime exposure to one or more PTEs followed patterns similar to those found among all adults. Adults with current "other" employment status (which includes those with disability) had higher past year PTSD estimates than adults currently employed full time or currently unemployed (Table 3.3). In addition, adults with family incomes of less than $20,000 per year had higher past year estimates of PTSD than adults with family incomes of $50,000-$74,999 and $75,000 or higher, respectively.

Finally, most correlates of past year PTSD among adults with lifetime exposure to one or more PTEs were similar to correlates among all adults,53 with the exception that no association existed between race/ethnicity and past year PTSD or between poverty level and past year PTSD after adjusting for lifetime exposure to one or more PTEs. P values for each nonsuppressed comparison are listed in Appendix Table B3.

3.3 Substance Use and Mental Health Indicators among Adults by Lifetime Exposure to One or More PTEs and Posttraumatic Stress

Table 3.4 displays the full set of estimates of each substance use, mental health, and physical health indicator by lifetime exposure to PTEs and presence of posttraumatic stress. Figure 3.1 and Figure 3.2 display these associations for key substance use and mental health indicators in graphical form.

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 greater than or equal to 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)
Figure 3.1. For long description follow 'D' link at lower right.     D
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)
Figure 3.2. For long description follow 'D' link at lower right.     D
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.

Lifetime Substance Use

The prevalence of lifetime illicit drug use was higher among adults with versus without lifetime exposure to one or more PTEs (60.0 vs. 45.9 percent; Table 3.4). Similarly, lifetime illicit drug use was higher among adults with versus without lifetime exposure to one or more PTEs followed by recurrent upsetting memories or flashbacks (the second trauma measure examined; 59.4 vs. 50.3 percent) and those with versus without past year PTSS (including PTSD, the third trauma measure examined; 70.3 vs. 51.3 percent). Similar results were observed for lifetime illicit drug use excluding marijuana.54,55 Comparisons of substance use prevalence among adults with versus without PTSD are not made because of data suppression due to the imprecision of estimates.

The significant associations between lifetime substance use indicators, exposure to one or more PTEs, and posttraumatic stress among adults with exposure to one or more PTEs had slightly different patterns than those among all adults. Among adults with lifetime exposure to one or more PTEs, the prevalence of illicit drug use other than marijuana, but not all illicit drug use, was higher among those with versus without past year PTSS (including PTSD; Table 3.5). Like the estimates made among all adults, associations between lifetime substance use indicators and past year PTSD were suppressed.

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 greater than or equal to 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)

Past Year Substance Use

The estimates for several past year substance use indicators were higher among adults with versus without lifetime exposure to one or more PTEs. They were also higher among adults with lifetime exposure to one or more PTEs followed by recurrent upsetting memories or flashbacks and those with past year PTSS (including PTSD; Table 3.4). For example, the estimates of past year illicit drug use, marijuana use, nonmedical use of psychotherapeutics, and tobacco use56 were higher for those with versus without lifetime exposure to one or more PTEs (18.8 vs. 13.3 percent, 14.7 vs. 10.1 percent, 7.0 vs. 4.9 percent, and 42.2 vs. 30.6 percent, respectively). Likewise, the estimates of past year any substance use disorder and of past year receipt of substance use treatment57 were higher for those with versus without lifetime exposure to one or more PTEs (10.1 vs. 7.7 percent and 1.9 vs. 1.0 percent, respectively).

Adults with versus without lifetime exposure to one or more PTEs followed by recurrent upsetting memories or flashbacks were more likely to use tobacco, have illicit drug dependence or abuse, or receive substance use treatment in the past year (42.2 vs. 34.1 percent, 4.4 vs. 2.3 percent, and 2.3 vs. 1.2 percent, respectively; Table 3.4). The estimates of all past year substance use indicators, except use of illicit drugs, were significantly higher for those with versus without past year PTSS. No significant differences in past year substance use indicators were noted between adults with versus without past year PTSD, although several of the estimates were suppressed.

Table 3.5 displays the full set of estimates of each substance use, mental health, and physical health indicator tested by past year PTSS status among adults with lifetime exposure to one or more PTEs, whereas Figure 3.3 and Figure 3.4 display these associations for key substance use and mental health indicators in graphical form.

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)
Figure 3.3. For long description follow 'D' link at lower right.     D
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)
Figure 3.4. For long description follow 'D' link at lower right.     D
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.

The significant associations between substance use indicators and past year PTSS (including PTSD) among adults with lifetime exposure to one or more PTEs (Table 3.5) followed patterns similar to associations examined among all adults. Among adults with lifetime exposure to one or more PTEs, those with past year PTSS had higher prevalence estimates of past year tobacco use, alcohol dependence or abuse, illicit drug dependence or abuse, any substance use disorder, and receipt of substance use treatment than those without past year PTSS. There were no significant differences between those with versus without past year PTSS among adults with lifetime exposure to one or more PTEs for past year illicit drug use, illicit drug use other than marijuana, marijuana use, and nonmedical use of psychotherapeutics. Other estimates for past year substance use and PTSD were suppressed.

Past Month Alcohol Use

Adults with lifetime exposure to one or more PTEs had higher past month binge alcohol use58 and heavy alcohol use59 estimates than those without lifetime exposure to one or more PTEs (29.6 vs. 23.4 percent and 9.5 vs. 6.5 percent, respectively; Table 3.5).

The past month alcohol use estimates did not differ by lifetime exposure to one or more PTEs followed by recurrent upsetting memories or flashbacks or past year PTSS status (either among all adults or among adults with lifetime exposure to one or more PTEs; Table 3.5). All past month alcohol use estimates by PTSD status were suppressed.

Past Year Mental Health Indicators

The estimates of each mental health indicator studied, past year any mental illness (AMI),60 serious mental illness (SMI),61 serious psychological distress (SPD),62 major depressive episode (MDE),63 suicidal thoughts,64 receipt of mental health treatment,65 and self-reported history of health care professional-diagnosed anxiety and depression, were higher for adults with lifetime exposure to one or more PTEs than for those without. The same pattern was seen among adults with lifetime exposure to one or more PTEs followed by recurrent upsetting memories or flashbacks versus those without and those with past year PTSS versus those without (Table 3.4). All estimates comparing those with versus without past year PTSD were suppressed.

Among adults with lifetime exposure to one or more PTEs, the patterns of estimates of each mental health indicator studied were similar to those found among all adults. Estimates for the mental health indicators were higher for adults with versus without past year PTSS (Table 3.5). In addition, among the subset of adults with lifetime exposure to one or more PTEs, the estimate for past year suicidal thoughts was higher for those with versus without past year PTSD (21.8 vs. 4.1 percent). The remainder of the estimates of mental health indicators by past year PTSD status were suppressed.

Lifetime Physical Health Conditions

Among all adults, the estimates of lifetime asthma, heart disease, high blood pressure, pneumonia, sexually transmitted disease, sinusitis, sleep apnea, and ulcer were significantly higher among adults with lifetime exposure to one or more PTEs than adults without (Table 3.4 and Figure 3.5). Similarly, the estimates of lifetime asthma, bronchitis, diabetes, high blood pressure, sexually transmitted disease, sinusitis, and ulcer were significantly higher among those with versus without lifetime exposure to one or more PTEs followed by recurrent upsetting memories or flashbacks. Lifetime estimates of asthma, bronchitis, sexually transmitted disease, sleep apnea, and ulcer were higher among adults with past year PTSS than adults without. Most estimates of physical conditions examined by past year PTSD status were suppressed; however, adults with past year PTSD were more likely than those without to have tinnitus (8.3 vs. 2.1 percent, respectively).

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)
Figure 3.5. For long description follow 'D' link at lower right.     D
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.

Among adults with lifetime exposure to one or more PTEs, the estimates for each of the physical health conditions examined did not significantly differ by past year PTSS status, and most estimates were suppressed by PTSD status (Table 3.5).

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 4.1 Summary of Significant Differences in Percentages of Lifetime Exposure to One or More PTEs and Posttraumatic Stress, by Demographic and Socioeconomic Characteristics 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
Characteristic 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; NH = not Hispanic/Latino; PTE = potentially traumatic event; PTSD = posttraumatic stress disorder; PTSS = posttraumatic stress symptoms.
NOTE: Definitions for standard terms are included in the endnotes.
— No significant differences at p < .05 level of significance.
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.
Age 18-25 < 26-49 and
50 or older
26-49 >
50 or older
50 or older <
18-25 and 26-49
Gender Females > males Females > males Females > males
Hispanic/Latino Origin
and Race
NH white >
NH other
NH white >
NH black/African
American
Education
Current Employment Other > full time Other > full time
and unemployed
Other > full time Other > full time
and unemployed
Poverty Level Less than 100% >
200% or more
Less than 100% >
200% or more
Family Income Less than $20,000 >
$75,000 or more
Less than $20,000
> $50,000-
$74,000 and
$75,000 or more
Less than $20,000
> $50,000-
$74,000 and
$75,000 or more
Less than $20,000
> $75,000 or more
Less than $20,000
> $50,000-
$74,000 and
$75,000 or more
Marital Status
Veteran Status Yes > no Yes > no

Most correlates of past year PTSD among adults with exposure to one or more PTEs were similar to correlates among all adults, with the exception that no association was found between race/ethnicity and past year PTSD after adjusting for exposure to one or more PTEs.

The prevalence of many of the substance use, mental health, and physical health indicators was higher among adults with versus without lifetime exposure to one or more PTEs, with lifetime exposure to one or more PTEs followed by recurrent upsetting memories or flashbacks, and with past year PTSS (including PTSD; see Table 4.2 for a summary of significant associations).

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 greater than or equal to 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 + + +     *

Associations between past year PTSS and substance use or mental health indicators were similar among all adults and among adults with lifetime exposure to one or more PTEs. For example, the prevalence of past year suicidal thoughts was more than 6 times as high among all adults with versus without past year PTSS (21.8 vs. 3.3 percent) and among adults with lifetime exposure to one or more PTEs with versus without past year PTSS (21.8 vs. 3.5 percent). These findings suggest that associations between past year PTSS and mental health and substance use indicators persist even after controlling for lifetime exposure to one or more PTEs. Significant associations found between physical health conditions and past year PTSS among all adults were not significant after controlling for lifetime exposure to one or more PTEs. All of the comparisons between physical conditions and PTSD were suppressed; however, low sample sizes and corresponding high standard errors may partly explain why significant differences were not found.

4.2 Comparison with Other Studies

This report did not statistically compare estimates of lifetime exposure to one or more PTEs and subsequent posttraumatic stress estimates from the Mental Health Surveillance Study (MHSS) with those found in prior U.S. nationally representative surveys for several reasons. Two of the outcome variables examined, lifetime exposure to one or more PTEs followed by flashbacks or recurrent upsetting memories and past year PTSS, as they were defined in the MHSS, were not comparable with any measures reported in prior nationally representative surveys. Differences in the estimates of the other two variables, lifetime exposure to one or more PTEs and PTSD, found in the current study compared with prior estimates may be due to variation in the definition and assessment methods of these variables in other studies reported in the literature.

The MHSS analyses found some of the same correlates of lifetime exposure to one or more PTEs as other prior U.S. nationally representative surveys. For example, this study demonstrated that not Hispanic/Latino white adults had higher estimates of lifetime exposure to one or more PTEs than not Hispanic/Latino "other" adults.8 It should be noted, however, that one aspect of the MHSS sampling frame may differentially affect comparisons of estimates between people across race/ethnicity groups. The MHSS interview was administered only in English, so the MHSS sample drawn from the larger NSDUH sample did not include those who completed the NSDUH interview in Spanish (i.e., were unable to complete an interview in English). Thus, the estimates produced by the MHSS sample may not be fully representative of the U.S. civilian, noninstitutionalized population.

Consistent with NESARC findings,67 the MHSS analyses also showed that lifetime exposure to one or more PTEs was associated with several health conditions and various indicators of mental health and substance use. Findings from the MHSS, however, found that estimated percentages of adults with lifetime exposure to one or more PTEs were higher among adults aged 26 to 49 and adults aged 50 or older than among adults aged 18 to 25, which has not been reported in prior U.S. nationally representative surveys.

For past year PTSS, prior studies have found females to have higher estimates of lifetime past year PTSS than males; the MHSS found a significant association between gender and past year PTSS as well. These analyses also identified significant associations between past year PTSS and several lifetime health conditions, mental health problems, and substance use indicators, which are consistent with some of the findings from NESARC that focused on associations with lifetime PTSS. The NESARC definition of lifetime PTSS, however, did not also include those with lifetime PTSD, so it was measured somewhat differently than in the MHSS. Finally, analyses of the MHSS data indicated that the percentage of adults with past year PTSS was higher among younger adults, those living in poverty and with low family income, and adults with "other" types of employment (including those on disability, as compared with those who were employed full time), which had not been reported previously in U.S. nationally representative surveys.

Correlates of PTSD identified in this study have similarities and differences compared with those found in the extant literature. For example, analyses of the MHSS found no differences in past year PTSD by gender, contrary to the NESARC study findings.5,10 In addition, not Hispanic/Latino white adults in these analyses had higher past year estimates of PTSD than not Hispanic/Latino black/African American adults, which had not been reported in the NESARC (which only reported lifetime PTSD correlates) or NCS-R studies.3,5 This study did note a significant association between PTSD and employment, replicating CPES lifetime PTSD correlate findings,9 and income, which was consistent with NESARC and NCS-R findings examining lifetime PTSD as a correlate.3,5 This study was unable to examine differences in past year estimates of various indicators of substance use, mental health problems, and physical health conditions by past year PTSD due to small sample sizes.

4.3 Strengths and Limitations

This study uses recent, nationally representative data to examine estimates and correlates of lifetime exposure to one or more PTEs and subsequent posttraumatic stress, including past year PTSS and PTSD. In the MHSS, trained clinical interviewers assessed lifetime exposure to one or more PTEs and subsequent posttraumatic stress, which allowed them to ask unstructured follow-up questions tailored to each respondent. This enabled the interviewers to use clinical judgment for determining the presence of lifetime exposure to one or more PTEs and posttraumatic stress measures. Thus, assessment of lifetime exposure to one or more PTEs and posttraumatic stress was not dependent upon the respondents' ability to understand the context of their experiences and behaviors. This is in contrast to fully structured instruments, which do not allow for clinicians to clarify if exposure to one or more PTEs reported by a respondent met Criterion A requirements.

Moreover, by focusing some of the analyses on the subset of adults who had lifetime exposure to one or more PTEs, it was possible to begin examining indicators of the progression from PTE exposure to the development of posttraumatic stress, including PTSD.

In addition to MHSS interviews being conducted in English only, another important caveat in interpreting the findings from the MHSS and other U.S. nationally representative surveys that have provided information about correlates of exposure to PTEs and posttraumatic stress involves the household-based nature of the sampling designs, which precludes the examination of some populations at higher risk for trauma exposure such as people living in institutions, homeless people not living in shelters, and active duty military personnel. Estimates from the active duty population participating in the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel found that nearly 11 percent of individuals on active duty screened positive for posttraumatic stress68 with sufficient PTSD symptoms in the past 30 days to warrant further diagnostic testing.69 The use of the symptom screener rather than a diagnostic instrument suggests that this estimate captured individuals who may have either PTSS or PTSD. Additionally, this descriptive study focuses on correlates of PTSS to better characterize these adults. However, no covariates or potential confounding influences were adjusted for in these analyses, no temporality can be established, and no causal influences can be suggested based upon this research.

This study is important because trauma exposure and PTSD are associated with significant social, personal, and economic costs.70 Trauma exposure and resulting posttraumatic stress both affect various aspects of physical and mental health, as well as treatment approaches. Because not everyone exposed to a PTE develops negative sequelae, it is important to identify factors that increase or decrease the risk of developing PTSS, including PTSD, as targets for prevention interventions. It is estimated that nearly half of adults (42.6 percent) with PTSD do not receive mental health treatment, and among those who do, only 40.4 percent are receiving minimally adequate treatment (23.2 percent of all adults with PTSD).71

Future research using multivariable modeling to control for potential confounding and additional research focusing on the examination of patterns of remission and risk factors for not remitting will be needed to identify important treatment targets. This investigation contributes to the Substance Abuse and Mental Health Services Administration's effort to monitor the extent of trauma and posttraumatic stress symptoms in the nation, determine associations with mental health and substance use problems as well as other deleterious effects, and develop and implement effective prevention, treatment, and recovery and resiliency support services for trauma and related sequelae.

The 2008-2012 National Survey on Drug Use and Health (NSDUH) Adult Clinical Interview data file provides the variables collected during the NSDUH interview and the Mental Health Surveillance Study clinical follow-up interview. This file is a restricteduse dataset that currently is not available as part of the NSDUH public-use file. Researchers can apply for online access to the data through the Substance Abuse and Mental Health Services Administration's (SAMHSA's) data portal at http://www.samhsa.gov/samhda.

The data portal is a secure virtual computing environment hosted by SAMHSA's Substance Abuse and Mental Health Data Archive that provides authorized researchers access to confidential data for approved research projects.

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

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2 American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

3 Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593-602. doi:10.1001/archpsyc.62.6.593

4 Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617-627. doi:10.1001/archpsyc.62.6.617

5 Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2011). Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Anxiety Disorders, 25(3), 456-465. doi:10.1016/j.janxdis.2010.11.010

6 Santiago, P. N., Ursano, R. J., Gray, C. L., Pynoos, R. S., Spiegel, D., Lewis-Fernandez, R., Friedman, M. J., & Fullerton, C. S. (2013). A systematic review of PTSD prevalence and trajectories in DSM-5 defined trauma exposed populations: Intentional and non-intentional traumatic events. PLoS One, 8(4), e59236. doi:10.1371/journal.pone.0059236

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35 Jackson, J. R. (2004). The National Survey of American Life: A study of racial, ethnic and cultural influences on mental disorders and mental health. International Journal of Methods in Psychiatric Research, 13(4), 196-207.

36 Jordan, B., Karg, R., Batts, K., Epstein, J., & Wiesen, C. (2008). A clinical validation of the National Survey on Drug Use and Health assessment of substance use disorders. Addictive Behaviors, 33(6), 782-798. doi:10.1016/j.addbeh.2007.12.007

37 Crippa, J. A., de Lima Osório, F., Del-Ben, C. M., Filho, A. S., da Silva Freitas, M. C., & Loureiro, S. R. (2008). Comparability between telephone and face-to-face structured clinical interview for DSM-IV in assessing social anxiety disorder. Perspectives in Psychiatric Care, 44(4), 241-247.

38 Hajebi, A., Motevalian, A., Amin-Esmaeili, M., Hefazi, M., Radgoodarzi, R., Rahimi-Movaghar, A., & Sharifi, V. (2012). Telephone versus face-to-face administration of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, for diagnosis of psychotic disorders. Comprehensive Psychiatry, 53(5), 579-583.

39 Kendler, K. S., Neale, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J. (1992). A population based twin study of major depression in women: The impact of varying definitions of illness. Archives of General Psychiatry, 49, 257-266.

40 Kessler, R., Abelson, J., Demler, O., Escobar, J. I., Gibbon, M., Guyer, M. E., Howes, M. J., Jin, R., Vega, W. A., Walters, E. E., Wang, P., Zaslavsky, A., & Zheng, H. (2004). Clinical calibration of DSM-IV diagnoses in the World Mental Health (WMH) version of the World Health Organization (WHO) Composite International Diagnostic Interview (WMH-CIDI). International Journal of Methods in Psychiatric Research, 13(2), 122-139.

41 Lee, S., Tsang, A., Lau, L., Mak, A., Ng, K. L., & Chan, D. M. (2008). Concordance between telephone survey classification and face-to-face structured clinical interview in the diagnosis of generalized anxiety disorder in Hong Kong. Journal of Anxiety Disorders, 22(8), 1403-1411.

42 Rohde, P., Lewinsohn, P. M., & Seeley, J. R. (1997). Comparability of telephone and face-to-face interviews in assessing axis I and axis II disorders. American Journal of Psychiatry, 154, 1593-1598.

43 Sobin, C., Weissman, M. M., Goldstein, R. B., Adams, P., Wickramaratne, P., Warner, V., & Lish, J. D. (1993). Diagnostic interviewing for family studies: Comparing telephone and face-to-face methods for the diagnosis of lifetime psychiatric disorders. Psychiatric Genetics, 3, 227-233.

44 RTI International. (2013). SUDAAN®, Release 11.0.1 [computer software]. Research Triangle Park, NC: RTI International.

45 Aldworth, J., Chromy, J. R., Davis, T. R., Foster, M. S., Packer, L. E., & Spagnola, K. (2012). Statistical inference report. In 2011 National Survey on Drug Use and Health: Methodological resource book (Section 14). Rockville, MD: Substance Abuse and Mental Health Services Administration.

46 Korn, E. L., & Graubard, B. I. (1990). Simultaneous testing of regression coefficients with complex survey data: Use of Bonferroni t-statistics. The American Statistician, 44, 270-276.

47 Center for Behavioral Health Statistics and Quality. (2013). 2012 National Survey on Drug Use and Health public use file codebook. Retrieved November 3, 2014, from https://www.icpsr.umich.edu/icpsrweb/NAHDAP/series/64/studies/34933

48 Center for Behavioral Health Statistics and Quality. (2014). 2012 National Survey on Drug Use and Health: Methodological resource book. Rockville, MD: Substance Abuse and Mental Health Services Administration.

49 "Not Hispanic/Latino other" includes adults classified as not Hispanic/Latino American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, Asian, or two or more races.

50 The percentage of adults with exposure to a lifetime traumatic event followed by recurrent upsetting memories or flashbacks was higher among adults with versus without lifetime asthma, bronchitis, diabetes, high blood pressure, sexually transmitted disease, sinusitis, ulcer, anxiety, or depression.

51 "Other" types of employment included students, people keeping house or caring for children full time, retired or disabled people, or other people not in the labor force.

52 Among adults with lifetime trauma exposure, the estimate of past year subclinical PTSD (including clinical PTSD) was higher for adults with versus without anxiety, and depression.

53 Among adults with lifetime trauma exposure, the estimated percentage of adults with past year clinical PTSD was higher for adults with versus without lifetime high blood pressure, sleep apnea, anxiety, and depression.

54 Illicit drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically.

55 Illicit drugs other than marijuana include cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used nonmedically.

56 Tobacco product use in the past year includes past year use of cigarettes, smokeless tobacco (i.e., chewing tobacco or snuff), and cigars and past month use of pipe tobacco.

57 Received substance use treatment refers to treatment received in order to reduce or stop illicit drug or alcohol use or for medical problems associated with illicit drug or alcohol use. It includes treatment received at any location, such as a hospital (inpatient), rehabilitation facility (inpatient or outpatient), mental health center, emergency room, private doctor's office, self-help group, or prison/jail.

58 Binge alcohol use is defined as drinking five or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days.

59 Heavy alcohol use is defined as drinking five or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other) on each of 5 or more days in the past 30 days.

60 AMI is defined as having a diagnosable mental, behavioral, or emotional disorder, other than a developmental or substance use disorder, that met the criteria found in DSM-IV.

61 SMI is defined as having a diagnosable mental, behavioral, or emotional disorder, other than a developmental or substance use disorder, that met the criteria found in DSM-IV and resulted in serious functional impairment.

62 SPD is defined as having a score of 13 or higher on the Kessler-6 scale during the past 30 days.

63 MDE is defined as in DSM-IV, which specifies a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of specified depression symptoms.

64 Suicidal thoughts is defined as having serious thoughts of suicide in the past year.

65 Mental health treatment/counseling is defined as having received inpatient care or outpatient care or having used prescription medication for problems with emotions, nerves, or mental health. Respondents were not to include treatment for drug or alcohol use. Respondents with unknown treatment/counseling information were excluded.

66 Friedman, M. J., Resick, P. A., Bryant, R. A., & Brewin, C. R. (2011). Considering PTSD for DSM-5. Depression and Anxiety, 28(9), 750-769. doi:10.1002/da.20767

67 Husarewycz, M. N., El-Gabalawy, R., Logsetty, S., & Sareen, J. (2014). The association between number and type of traumatic life experiences and physical conditions in a nationally representative sample. General Hospital Psychiatry, 36(1), 26-32.

68 Weathers, F. W., Litz, B. T., Herman, D., Huska, J., & Keane, T. (1994). The PTSD checklist—Civilian version (PCL-C). Boston, MA: National Center for PTSD.

69 Bray, R. M., Pemberton, M. R., Lane, M. E., Hourani, L. L., Mattiko, M. J., & Babeu, L. A. (2010). Substance use and mental health trends among U.S. military active duty personnel: Key findings from the 2008 DoD Health Behavior Survey. Military Medicine, 175(6), 390-399.

70 Kessler, R. C. (2000). Posttraumatic stress disorder: The burden to the individual and to society. Journal of Clinical Psychiatry, 61(Suppl 5), 4-12; discussion 13-14.

71 Wang, P. S., Lane, M., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2005). Twelve-month use of mental health services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 629-640. doi:10.1001/archpsyc.62.6.629

Footnotes

a NSDUH respondents who agreed to participate in the MHSS at the time of their NSDUH interview are classified as agreeing to participate.

b Originally, the MHSS was designed to collect 1,500 cases in 2008 and 500 cases in subsequent years. The National Institute of Mental Health provided funding to augment the sample by 1,000 cases in 2011 and 2012. Analyses conducted for this report included 1,500 clinical interviews completed in 2008, 520 completed in 2009, 516 completed in 2010, 1,495 completed in 2011, and 1,622 completed in 2012.

c The WTADJX procedure in SUDAAN®44 calculated SEs in a way that accounted for the weights in the MHSS clinical sample being calibrated to estimated totals derived from the NSDUH main interview sample (i.e., the post-stratification adjustment). For more details, see Sections 5.5 and 5.6 in Chapter 5 of the MHSS operations report (2008-2012).19 This method of calculating SEs was thus different from the method used in the main NSDUH study analyses.

d When comparing prevalence estimates, one can test the null hypothesis (no difference between rates) against the alternative hypothesis (there is a difference in prevalence rates) using the standard t-test (with the appropriate degrees of freedom) for the difference in proportions test.

e Under the null hypothesis that there is no difference among m estimated values, a Bonferroni adjustment uses the following inequality: the probability that at least one of the q = m(m−1)/2 absolute pairwise differences across the m estimates is greater than a critical value (making the estimated values themselves significantly different) is less than or equal to the sum of the probabilities that each absolute pairwise difference is greater than the critical value. For example, when the null hypothesis is correct, setting the significant level for each of q pairwise differences at .05/q will find an overall significant difference among m estimated values at the 5 percent level no more than 5 percent of the time. The inequality holds whether or not the estimates being compared are independent. When the inequality is strict, the resulting Bonferroni adjustment is conservative.

f Details on the statistical imputation for NSDUH variables can be found in the 2012 NSDUH final analytic codebook introduction and the 2012 NSDUH Methodological Resource Book.

g That is, they experienced lifetime exposure to one or more PTEs, followed by nightmares, flashbacks, thoughts they could not get rid of, or being upset when in a situation that reminded them of the event.

h In other words, they met DSM-IV PTSD Criterion A (lifetime exposure to one or more PTEs and response that involved intense fear, helplessness, or horror), 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 (includes adults who met criteria for clinical PTSD as well).

i Based on definitions found in the DSM-IV, 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 PTSD also were classified as having at least past year PTSS.

Logo: Department of Health & Human Services - U S A The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.
The CBHSQ Data Review is published periodically by the Center for Behavioral Health Statistics and Quality, SAMHSA. All material appearing in this report is in the public domain and may be copied without permission from SAMHSA. This report is available online: http://www.samhsa.gov/data/. Citation of the source is appreciated. For questions about this report, please e-mail cbhsqhelp@samhsa.hhs.gov or call 240-276-1250.

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

Page E.1 of the SCID-I (for DSM-IV-TR) interview section to assess past year PTSD. For long description follow 'D' link at lower right.     D
Page E.2 of the SCID-I (for DSM-IV-TR) interview section to assess past year PTSD. For long description follow 'D' link at lower right.     D
Page E.3 of the SCID-I (for DSM-IV-TR) interview section to assess past year PTSD. For long description follow 'D' link at lower right.     D
Page E.4 of the SCID-I (for DSM-IV-TR) interview section to assess past year PTSD. For long description follow 'D' link at lower right.     D
Page E.5 of the SCID-I (for DSM-IV-TR) interview section to assess past year PTSD. For long description follow 'D' link at lower right.     D
Page E.6 of the SCID-I (for DSM-IV-TR) interview section to assess past year PTSD. For long description follow 'D' link at lower right.     D
Page E.7 of the SCID-I (for DSM-IV-TR) interview section to assess past year PTSD. For long description follow 'D' link at lower right.     D

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 is greater than or equal to 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 is greater than or equal to 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 is greater than or equal to 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 description, Figure 2.1: Figure 2.1 is a flowchart showing the routing logic for respondents in the PTSD module. Respondents had to affirm lifetime exposure to one or more PTEs (DSM-IV PTSD Criterion A1). They then had to affirm that they had symptoms of re-experiencing the event or becoming very distressed when recalling the event. If respondents met both Criteria A1 and A2 (experienced an event that 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), then they were assessed for symptoms to meet Criterion B (had at least 1 of 5 re-experiencing symptoms in the past year). If Criterion B was met, then the respondents were further assessed for meeting Criteria C (had at least 3 of 7 avoidance symptoms in the past year), D (had at least 2 of 5 hyperarousal symptoms in the past year), E (experienced a disturbance that lasted for at least 1 month), and F (had symptoms that caused clinically significant distress or impairment). If respondents met Criteria A through F, then they were determined to have past year PTSD. If they met Criteria A and B and had at least one Criterion C symptom, they were determined to have past year PTSS.

Long description end. Return to Figure 2.1.

Long description, Figure 3.1: Figure 3.1 is a bar chart showing lifetime exposure to one or more PTEs versus no lifetime exposure to PTEs for past year illicit drug use (18.8 vs. 13.3 percent), past year tobacco use (42.2 vs. 30.6 percent), past year substance use disorder (10.1 vs. 7.7 percent), and past month binge drinking (29.6 vs. 23.4 percent). Differences between the lifetime exposure to one or more PTEs and no lifetime exposure to PTEs groups were significant at the p < .05 level for all substance use categories.

Long description end. Return to Figure 3.1.

Long description, Figure 3.2: Figure 3.2 is a bar chart showing lifetime exposure to one or more PTEs versus no lifetime exposure to PTEs for any mental illness (23.2 vs. 14.3 percent), serious mental illness (6.1 vs. 2.4 percent), serious psychological distress (14.4 vs. 8.1 percent), major depressive episode (10.1 vs. 4.3 percent), suicidal thoughts (4.4 vs. 3.1 percent), and received mental health treatment/counseling (17.8 vs. 10.4 percent). Differences between the lifetime exposure to one or more PTEs and no lifetime exposure to PTEs groups were significant at the p < .05 level for all mental health categories.

Long description end. Return to Figure 3.2.

Long description, Figure 3.3: Figure 3.3 is a bar chart showing past year PTSS versus no past year PTSS for past year illicit drug dependence or abuse (21.9 vs. 18.9 percent), past year tobacco use (54.3 vs. 41.7 percent), past year substance use disorder (21.5 vs. 9.6 percent), and past month binge drinking (28.0 vs. 30.0 percent). Differences between the past year PTSS and no past year PTSS groups were significant at the p < .05 level for past year tobacco use and past year substance use disorder.

Long description end. Return to Figure 3.3.

Long description, Figure 3.4: Figure 3.4 is a bar chart showing past year PTSS versus no past year PTSS for any mental illness (75.6 vs. 20.4 percent), serious mental illness (37.1 vs. 4.4 percent), serious psychological distress (58.5 vs. 12.1 percent), major depressive episode (49.9 vs. 8.0 percent), suicidal thoughts (21.8 vs. 3.5 percent), and received mental health treatment/counseling (57.1 vs. 15.4 percent). Differences between the past year PTSS and no past year PTSS groups were significant at the p < .05 level for all mental health categories.

Long description end. Return to Figure 3.4.

Long description, Figure 3.5: Figure 3.5 is a bar chart showing lifetime exposure to one or more PTEs versus no lifetime exposure to PTEs for asthma (15.3 vs. 8.3 percent), heart disease (8.0 vs. 4.0 percent), high blood pressure (27.9 vs. 21.4 percent), pneumonia (6.6 vs. 4.6 percent), sexually transmitted disease (5.3 vs. 3.0 percent), sinusitis (14.5 vs. 9.1 percent), sleep apnea (6.6 vs. 4.4 percent), and ulcer (4.8 vs. 2.4 percent). Differences between the lifetime exposure to one or more PTEs and no lifetime exposure to PTEs groups were significant at the p < .05 level for all physical health categories.

Long description end. Return to Figure 3.5.

Long Descriptions – Appendix A

Long description, Page E.1: This is page E.1 of the SCID-I (for DSM-IV-TR) interview section to assess the first anxiety disorder assessed, past year PTSD. There is a key at the bottom of the page that indicates that circling a response of "?" means "inadequate information," "1" means "absent or false," "2" means "subthreshold," and "3" means "threshold or true." There is a question about whether the respondent ever was exposed to an upsetting event and examples of these types of events are provided. If the respondent says no, the interview skips the remaining questions on the page and the next several pages, continuing the interview on page E.9. If the respondent says "yes" and the interviewer circles "3," there is a table that follows, labeled "Traumatic Events List," which the interviewer can fill in to list a brief description of the traumatic event, the date (month/yr) of exposure, and age at exposure. The next two questions assess whether the respondent has ever experienced the traumatic event coming back in nightmares, flashbacks, or thoughts hard to get rid of or if being in a situation that reminded the respondent of the traumatic event made the respondent very upset. If the respondent answers "no" to both questions, the interviewer is directed to skip the respondent ahead and continue the interview on page E.9. If "yes," the interviewer circles the number "3," which means "threshold or true" beside the question and continues the interview on page E.2.

End long description. Return to page E.1.

Long description, Page E.2: This is page E.2 of the SCID-I (for DSM-IV-TR) interview section to assess past year PTSD. This page shows additional questions for the interviewer to ask the respondent to assess whether past year PTSD is present. The questions are in the left-hand column. In the right-hand column are the corresponding PTSD criteria from the DSM-IV-TR, with a place for the interviewer to circle a corresponding number for each item. There is a key at the bottom of the page that indicates that circling a response of "?" means "inadequate information," "1" means "absent or false," "2" means "subthreshold," and "3" means "threshold or true." First, the interviewer asks the respondent to identify the one trauma that has had the greatest effect on the respondent. The interviewer then asks both PTSD criteria A questions, labeled as E3 and E4. If both questions are endorsed as a "1," the interviewer is directed to skip the respondent ahead to page E.9. The first two PTSD criteria B items are assessed as well on this page, labeled E5 and E6.

End long description. Return to page E.2.

Long description, Page E.3: This is page E.3 of the SCID-I (for DSM-IV-TR) interview section to assess past year PTSD. This page shows additional questions for the interviewer to ask the respondent to assess whether past year PTSD is present. The questions are in the left-hand column. In the right-hand column are the corresponding PTSD criteria from the DSM-IV-TR, with a place for the interviewer to circle a corresponding number for each item. There is a key at the bottom of the page that indicates that circling a response of "?" means "inadequate information," "1" means "absent or false," "2" means "subthreshold," and "3" means "threshold or true." The third, fourth, and fifth items used to assess PTSD criteria B are listed. At the bottom of the page, the interviewer indicates whether at least one criteria B symptom is present. If it is not, the interviewer is directed to skip the respondent ahead to page E.9.

End long description. Return to page E.3.

Long description, Page E.4: This is page E.4 of the SCID-I (for DSM-IV-TR) interview section to assess past year PTSD. The questions are in the left-hand column. In the right-hand column are the corresponding PTSD criteria from the DSM-IV-TR, with a place for the interviewer to circle a corresponding number for each item. There is a key at the bottom of the page that indicates that circling a response of "?" means "inadequate information," "1" means "absent or false," "2" means "subthreshold," and "3" means "threshold or true." The first four items used to assess PTSD criteria C are listed.

End long description. Return to page E.4.

Long description, Page E.5: This is page E.5 of the SCID-I (for DSM-IV-TR) interview section to assess past year PTSD. The questions are in the left-hand column. In the right-hand column are the corresponding PTSD criteria from the DSM-IV-TR, with a place for the interviewer to circle a corresponding number for each item. There is a key at the bottom of the page that indicates that circling a response of "?"means "inadequate information," "1" means "absent or false," "2" means "subthreshold," and "3" means "threshold or true." The fifth, sixth, and seventh items used to assess PTSD criteria C are listed. At the bottom of the page, the interviewer indicates whether at least three C symptoms are present. If not, the interviewer is directed to skip the respondent ahead to page E.9.

End long description. Return to page E.5.

Long description, Page E.6: This is page E.6 of the SCID-I (for DSM-IV-TR) interview section to assess past year PTSD. The questions are in the left-hand column. In the right-hand column are the corresponding PTSD criteria from the DSM-IV-TR, with a place for the interviewer to circle a corresponding number for each item. There is a key at the bottom of the page that indicates that circling a response of "?"means "inadequate information," "1" means "absent or false," "2" means "subthreshold," and "3" means "threshold or true." The five items used to assess PTSD criteria D are listed. At the bottom of the page, the interviewer indicates whether at least two criteria D symptoms are present. If not, the interviewer is directed to skip the respondent ahead to page E.9.

End long description. Return to page E.6.

Long description, Page E.7: This is page E.7 of the SCID-I (for DSM-IV-TR) interview section to assess past year PTSD. The questions are in the left-hand column. In the right-hand column are the corresponding PTSD criteria from the DSM-IV-TR, with a place for the interviewer to circle a corresponding number for each item. There is a key at the bottom of the page that indicates that circling a response of "?"means "inadequate information," "1" means "absent or false," "2" means "subthreshold," and "3" means "threshold or true." Criterion E is assessed first, and if the interviewer circles "1," the interviewer is directed to skip the respondent ahead to page E.9. Criterion F is assessed next, and if the interviewer circles "1," the interviewer is directed to skip the respondent ahead to page E.9. The last question asks the interviewer if each of PTSD criteria A, B, C, D, E, and F are coded as "3" and present in the past year so that the interviewer can indicate that PTSD was present in the past year. If not, the interviewer directs the respondent ahead to page E.9.

End long description. Return to page E.7.

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