Study Finds Excess Mortality Rates among Post-9/11 Veterans Compared with General US Population, Particularly among Veterans with TBI
While research from previous wars suggested that Veterans benefitted from lower all-cause mortality, recent research suggests that this so-called “healthy soldier effect” may be disappearing among post-9/11 Veterans. The number and length of deployments over 20 years of war, as well as the subsequent psychological toll, including high prevalence of PTSD and depression, could be contributing factors. Another factor could be the scale and impact of exposure to traumatic brain injury (TBI), one of the signature wounds of the post-9/11 conflicts. This retrospective cohort study sought to assess the total all-cause and cause-specific mortality burden – and to estimate the total number of excess deaths among post-9/11 Veterans with and without exposure to TBI compared with the total US population. Using data from the Department of Defense (DoD), VA, and the Centers for Disease Control and Prevention (CDC), including the Joint DoD-VA Mortality Data Repository-National Death Index (2002-2018), investigators identified 2.5 million Veterans who served on active duty after 9/11/2001 with three or more years of care in the Military Health System (MHS) – or Veterans with three or more years of care in the MHS and two or more years of VA care before the end of 2018.
- Post-9/11 Veterans experienced excess all-cause and cause-specific mortality compared with the total US population, which was exacerbated by exposure to traumatic brain injury. While Veterans exposed to moderate/severe TBI accounted for only 3% of the total post-9/11 Veteran population, they accounted for 34% of total excess deaths observed, which was 11-fold higher than would otherwise be expected.
- The top five causes of death for Veterans were: 1) accident, 2) suicide, 3) cancer, 4) cardiovascular disease, and 5) homicide. Adjusted mortality rates for each were higher among Veterans with mild and moderate/severe TBI, compared with Veterans with no TBI. While excess accident, suicide, and homicide mortality was greater among those with TBI across all age groups, excess mortality from cardiovascular disease and cancer was primarily in Veterans >55 years with moderate/severe TBI.
- After 20 years of war, it is vital to focus attention on what puts Veterans at risk for accelerated aging and increased mortality, and how it can be mitigated. Also, although mortality data with TBI exposure information is not available for the total US population, it is reasonable to expect similar increases in mortality rates for civilians with TBI exposures. Thus, these results have implications that extend beyond the Veteran population.
- Inclusion criteria required three years of DoD data, which excluded individuals who left military service without care in three years.
- TBI diagnoses and severity levels are an approximation and may not fully represent the exposure to or severity of injuries sustained.
This study was supported by the DoD and VA. Dr. Pugh and Ms. Amuan are part of HSR&D’s Informatics, Decision-Enhancement and Analytic Sciences Center in Salt Lake City, UT.
Howard J, Stewart I, Amuan M, Janak J, and Pugh MJ. Association of Traumatic Brain Injury with Mortality among Military Veterans Serving after September 11, 2001. JAMA Network Open. February 11, 2022;5(2):e2148150.