Suicide, accidents, and hepatitis – The leading causes of death for Veterans in their first year of PTSD treatment

A new study in the American Journal of Preventive Medicine identifies and stratifies the mortality risks by age group, providing valuable insights for guiding prevention and treatment efforts

Ann Arbor, June 24, 2019

According to a new study in the American Journal of Preventive Medicine, published by Elsevier, United States Veterans seeking treatment for posttraumatic stress disorder (PTSD) are at increased risk of death compared with the general population. Veterans with PTSD are twice as likely to die from suicide, accidental injury, and viral hepatitis than the general population. Veterans with PTSD are also more likely to die from diabetes and chronic liver disease than the general population.

“Our findings suggest that treatment-seeking Veterans with PTSD, including young Veterans and women, are dying from largely preventable causes compared with the general population. PTSD is therefore a major public health concern and a priority for preventive health care,” explained lead investigator Jenna A. Forehand, MD, MPH, Veterans Affairs Medical Center, White River Junction, VT, US.

This is the first study to investigate specific causes of death by age group among all-era, treatment-seeking Veterans with PTSD and compare death rates to the US general population. Veterans with PTSD had a significant increase in all-cause mortality in the year following initiation of treatment; 1.1 percent of them died, which is a 5 percent higher incidence than in the general population. Veterans with PTSD had a two-fold increase in death from suicide, accidental injury, and viral hepatitis compared with the US population. Death from diabetes and chronic liver disease was also significantly higher for Veterans with PTSD. During the first year of VA PTSD treatment, younger Veterans with PTSD were more likely to die from suicide and accidental injury, whereas middle-aged and older Veterans were more likely to die from heart disease and malignant neoplasms. Among individuals dying from accidental injury, more than half died of poisoning, which could include some misclassified suicides.

This retrospective cohort study identified the leading causes of death among 491,040 Veterans who initiated PTSD treatment at any Department of Veterans Affairs Medical Center from 2008 to 2013. Of the initial cohort, 5,215 of them died within the first year of care; the mean age was 48.5 years, 90.7 percent were male, 63.5 percent were of white race, and 34.9 percent served in the wars in Iraq and Afghanistan.

Causes of death during the first year of treatment were grouped according to age (18-34, 35-64, and 65 or older). To statistically compare the observed mortality among Veterans in PTSD treatment with the general population, standardized mortality ratios were calculated from age- and sex-matched mortality tables of the 2014 US population.

Illustration showing the leading causes of death in Veterans treated for PTSD
Leading causes of death in Veterans treated for PTSD. Credit: Jenna Forehand, MD, MPH.

Because of advances in medicine and technology, Veterans who served in recent conflicts are more likely to survive combat injuries than previous generations. As a result, the prevalence of PTSD, pain disorders, and opioid use has increased among survivors. As Veterans with PTSD and comorbid pain may be at increased risk of opioid use disorder, the investigators posit that opioids may play a role in accidental injury, suicide, and hepatitis-related deaths, especially in young Veterans with PTSD. Understanding the complex nature of PTSD and its associated mortality risks is important for developing targeted interventions in this age group.

“Future studies should develop preventive interventions that target PTSD and comorbid depression, pain disorder, and substance use to lessen the risk of suicide, accidental poisoning, and viral hepatitis in Veterans with PTSD. Similarly, lifestyle modifications may reduce the risk of diabetes and chronic liver disease in this patient population. Veterans seeking treatment for PTSD should receive comprehensive education on the benefits of diet and exercise and the risks of chronic stress and substance use,” commented Dr. Forehand.


Notes for editors
The article is “Causes of Excess Mortality in Veterans Treated for Posttraumatic Stress Disorder,” by Jenna A. Forehand, MD, MPH, Talya Peltzman, MPH, Christine Leonard Westgate, MS, Natalie B. Riblet, MD, MPH, Bradley V. Watts, MD, MPH, and Brian Shiner, MD, MPH ( It appears in advance of the American Journal of Preventive Medicine, volume 57, issue 2 (August 2019) published by Elsevier.

Full text of this article is available to credentialed journalists upon request; contact Jillian B. Morgan at +1 734 936 1590 or Journalists who wish to interview the authors should contact Jenna A. Forehand at

This work was funded by the VA National Center for Patient Safety Center of Inquiry Program.

About the American Journal of Preventive Medicine
The American Journal of Preventive Medicine is the official journal of the American College of Preventive Medicine and the Association for Prevention Teaching and Research. It publishes articles in the areas of prevention research, teaching, practice and policy. Original research is published on interventions aimed at the prevention of chronic and acute disease and the promotion of individual and community health. The journal features papers that address the primary and secondary prevention of important clinical, behavioral and public health issues such as injury and violence, infectious disease, women's health, smoking, sedentary behaviors and physical activity, nutrition, diabetes, obesity, and alcohol and drug abuse. Papers also address educational initiatives aimed at improving the ability of health professionals to provide effective clinical prevention and public health services. The journal also publishes official policy statements from the two co-sponsoring organizations, health services research pertinent to prevention and public health, review articles, media reviews, and editorials.

About Elsevier
Elsevier is a global information analytics business that helps scientists and clinicians to find new answers, reshape human knowledge, and tackle the most urgent human crises. For 140 years, we have partnered with the research world to curate and verify scientific knowledge. Today, we’re committed to bringing that rigor to a new generation of platforms. Elsevier provides digital solutions and tools in the areas of strategic research management, R&D performance, clinical decision support, and professional education; including ScienceDirect, Scopus, SciVal, ClinicalKey and Sherpath. Elsevier publishes over 2,500 digitized journals, including The Lancet and Cell, 39,000 e-book titles and many iconic reference works, including Gray's Anatomy. Elsevier is part of RELX, a global provider of information-based analytics and decision tools for professional and business customers.

Media contact
Jillian B. Morgan, MPH, Managing Editor
+1 734 936 1590