title: The impact of Purple Heart commendation and PTSD on mortality rates in older veterans.
abstract: BACKGROUND
  To determine whether having received a Purple Heart (PH) or having been diagnosed with posttraumatic stress disorder (PTSD) affected mortality in older veterans.
  
  
  METHODS
  We compared mortality rates of older veterans with a PH but without PTSD (PH+/PTSD-) to veterans with a PH and PTSD (PH+/PTSD+), veterans without a PH but with PTSD (PH-/PTSD+), and a comparison group without a PH or PTSD (PH-/PTSD-). Administrative data from the Veterans Integrated Service Network 16 were collected between 10/01/97 and 09/30/99 for veterans who were 65 years or older. Proportional hazards regression was used to compare the survival times for the four groups (n = 10,255) from entry into the study until death or study termination (9/30/2008). The Charleson co-morbidity index was used to control for potential co-morbid illness burden differences between the groups.
  
  
  RESULTS
  Older veterans with a PH (PH+/PTSD- and PH+/PTSD+) had significantly lower mortality rates than PH-/PTSD- veterans (hazard ratio [HR] = 0.6, 95% confidence interval [CI] 0.5 to 0.6, P<.0001; and HR = 0.5, 95% CI 0.4 to 0.7, P<.0001). The PH-/PTSD+ group had a higher mortality rate than the PH-/PTSD- group (HR = 1.1, 95% CI 1.0 to 1.2, P<.01).
  
  
  CONCLUSIONS
  Veterans who had PH citations and survived into their seventh decade had half the mortality rate of veterans without PH citations with or without PTSD. Veterans with PTSD but without a PH had a significantly higher mortality rate compared to (PH-/PTSD-). Veterans who suffer combat injury without developing PTSD may provide a useful study population for determining the factors that confer resilience.
authors.affiliation: Center for Mental Health and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas 72114, USA. timothy.kimbrell@va.gov
authors.forename: Tim
authors.initials: T
authors.lastname: Kimbrell
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Pyne
authors.forename: Mark E
authors.initials: ME
authors.lastname: Kunik
authors.forename: Kathy M
authors.initials: KM
authors.lastname: Magruder
authors.forename: Nancy J
authors.initials: NJ
authors.lastname: Petersen
authors.forename: Hong-Jen
authors.initials: HJ
authors.lastname: Yu
authors.forename: Teresa J
authors.initials: TJ
authors.lastname: Hudson
authors.forename: Paul E
authors.initials: PE
authors.lastname: Schulz
authors.forename: Salah U
authors.initials: SU
authors.lastname: Qureshi
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D047869:Korean War; D008297:Male; D013313:Stress Disorders, Post-Traumatic / Q000453:epidemiology / Q000401:mortality*; D014481:United States / Q000453:epidemiology; D014728:Veterans / Q000523:psychology*; D047789:World War II; D014947:Wounds and Injuries / Q000453:epidemiology / Q000401:mortality*