The mental health of sons and daughters of Australian Vietnam veterans

The mental health of sons and daughters of Australian Vietnam veterans Abstract Background War service increases the risk of post-traumatic stress disorder (PTSD) to combatants, and has been shown to increase the risk of PTSD in their offspring. The extent to which there is an excess compared with the general population is not yet established, nor whether PTSD increases the risk of other psychiatric problems. Methods A national sample of 133 sons and 182 daughters of a cohort of 179 Australian Vietnam veterans’ families were assessed in person, using structured psychiatric interviews. The prevalence of trauma exposures, DSM-IV (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition) diagnoses and suicidality were compared with the Australian Bureau of Statistics’ 2007 National Survey of Mental Health and Wellbeing data matched for age and sex. The risk of mental health problems potentially attributable to PTSD was also assessed. Results Sons and daughters were more likely than population expectations to report exposures to natural disasters, fire or explosions and transport accidents, and sons more likely to report exposure to toxic chemicals whereas daughters were more likely to report sexual assault. Sons and daughters had higher prevalences of alcohol and other substance dependence, depression and anxiety, and PTSD, and children’s PTSD was associated with substance dependence, depression and suicidal ideation. There were strong associations between children’s PTSD and comorbid conditions of substance use disorders, depression and anxiety. Conclusions Higher rates of mental health problems in veterans’ families, together with comorbidity with PTSD and the link between veterans’ and children’s PTSD, suggest that the effects of trauma may continue into subsequent generations. Epidemiology, PTSD, Vietnam veterans, offspring, intergenerational Key Messages Adult children of Australian Vietnam veterans are at higher risk of exposure to potential trauma and posttraumatic stress disorder than the background Australian population. Sons of veterans had higher risks for substance dependence and abuse, depression and suicidal ideation than expected, and daughters had higher risks for alcohol and drug dependence, depression, PTSD and generalized anxiety disorder than population expectations, and lower risk for suicidal ideation but higher risk for planning. PTSD in children is accompanied by significant comorbidity that is differentially distributed between sons and daughters, with daughters bearing significant comorbid alcohol, drug and cannabis dependence, depression, anxiety, social phobia and suicidal ideation. PTSD in war veterans transmissible to their children may have further attributable risks of psychiatric comorbidity in their children’s adulthood and has implications for an epidemic of post-conflict mental ill health in families in war-torn countries. Introduction War service and combat are known to be toxic to veterans’ post-war physical and mental health, particularly giving rise to post-traumatic stress disorder (PTSD),1–3 and may also be toxic to veterans’ families.4 Families of veterans often have to contend with conflict and rigidity in family functioning,5,6 and experience significant distress and relationship dysfunction,4 higher levels of carer burden on their partners and lower levels of marital adjustment and poorer parenting if the veteran has PTSD.7–9 PTSD in war veterans has been linked to increased risk of domestic violence,10–13 and psychiatric problems in their wives,5,14,15 and is strongly associated with suicidality in veterans and their wives.16 PTSD in a parent increases the risk of PTSD in their offspring,7–20 in what is termed intergenerational transmission of PTSD. This has been empirically demonstrated in Australian veterans’ families.20 Given that PTSD is more prevalent in veterans than the general civilian population, it might be expected that veterans’ children would also have higher prevalence of PTSD than the background population if their own risk of PTSD is enhanced by an intergenerational risk of PTSD. Moreover, PTSD may not be the only hazard in veterans’ children’s lives, since it is well established from studies of Vietnam21,22 that veterans also experience higher risks for other mental health problems such as substance use disorders such as alcohol dependence and abuse, as well as depression and anxiety.22 Since PTSD is known to be accompanied by significant comorbidity,23 it would also be expected that, if PTSD in a veteran parent increases the risk of PTSD in his children, then this should also be accompanied by a rise in the risk of other diagnoses such as depression and substance use disorders as comorbid companions of their own PTSD. We have already reported that veteran alcohol disorder was associated with increased risk of alcohol dependence and generalized anxiety in his sons, and alcohol and substance dependence, recurrent depression and social phobia in his daughters.20 Given veterans’ higher risk of alcohol disorders, this would imply an increased risk of these problems also in sons and daughters of the veterans. The degree to which PTSD in veterans’ children is responsible for any increased risk of comorbidity remains unknown, but if PTSD in a veteran father increases the risk of PTSD in his offspring, and those offspring also have concurrent comorbidity in addition to the background population risk, then this should also predict higher rates of mental health disorders in the population which are potentially attributable to this increased risk of PTSD. It is always possible that veterans’ active lifestyles and attraction to hazardous activities after service could increase the risk of his children’s exposure to potentially traumatic experiences. We have reported that PTSD in a veteran does not increase the risk of exposure to potentially traumatic events in daughters, and is only sporadically associated with traumatic events in sons, most of which were not traumagenic.20 However, it is not yet established whether veterans’ children have a higher risk of trauma exposure than would be found in the general background population. If sons and daughters have higher prevalence of exposures, then this might also predict higher rates of PTSD in sons and daughters irrespective of whether their father had PTSD. All of these considerations would lead to the hypotheses that there would be an increased risk of trauma exposure, increased risk of PTSD and increased risk of other mental health problems in veterans’ children compared with the general background population, but these are yet to be tested against empirical evidence. This study attempts to fill this gap in knowledge of the possible ripple effects of war service in veterans’ post-war families. The aims of the study were 3-fold: to establish the prevalence of exposure to trauma, DSM-IV ((Diagnostic and Statistical Manual of Mental Disorders Fourth Edition) mental health diagnoses and suicidality in sons and daughters of Australian Vietnam veterans; to compare these with contemporaneous age-sex matched Australian population data; and to explore the relationship of children’s PTSD to other mental health diagnoses and assess the attributable risk of mental health comorbidity due to PTSD. Methods This study is nested within a cohort study of Australian Vietnam veterans1–13,24 who had been posted to Vietnam during the 10-years of Australian involvement (1962-72). Veterans were personally assessed 22.0 years [standard deviation (SD) = 1.9] and 36.1 years (SD = 1.9) after return to Australia. Response bias assessment found that respondents at both waves had higher Army intelligence test scores and fewer absent without leave (AWOL) charges than non-respondents. The physical and mental health of the veterans, including psychiatric diagnoses and their relation to combat, have been presented previously from the first1,2,24 and second3 assessments. At the second assessment (2006-08), veterans’ adult children (aged 18+) were enumerated and veterans requested to provide their contact details. Of the 450 veterans interviewed, 352 (78.2%) gave consent to approach their child(ren), 55 (12.2%) refused and 43 (9.50%) denied having children. Veteran consent was not associated with veteran PTSD or any veteran psychiatric diagnosis except alcohol abuse/dependence [odds ratio (OR) (95% CI) = 0.48 (0.26, 0.83), P = 0.019]. Sons and daughters were interviewed in person at locations throughout Australia in the period July 2012–July 2014. PTSD was assessed using the Clinician-administered PTSD Scale (CAPS)25 for DSM-IV, and general psychiatric status was assessed with the Composite International Diagnostic Interview (CIDI version 2.1)26 for DSM-IV. The version of the CIDI was that used by the Australian Bureau of Statistics (ABS) in the Australian National Survey of Mental Health and Wellbeing 1997,27 which was also used for the veteran wave 2 interviews.3 Personality disorders were not included in the CIDI. The PTSD ‘A’ criterion of trauma exposure was established with a checklist of potentially traumatic exposures, such as natural disasters, assaults, accidents and other traumas. This preceded identification and recounting of their worst experiences, to establish the focal experiences for symptom assessment. In the CAPS, the symptom threshold criteria of frequency > 1 and intensity > 2 (F1-I2) was used for individual symptom significance.28,29 All interviewers in the studies were masters or doctoral-level clinical or research psychologists. All study subjects gave informed written consent before participation; the study received approval from the Human Research Ethics Committee of the University of Sydney (#14340). Statistical analysis Data analysis used SPSS V20.0.30 The lifetime prevalences in sons and daughters were compared with age-sex matched prevalences of diagnoses that were available from the ABS ‘confidentialised unit record file’ (curf) from the 2007 National Survey of Mental Health and Wellbeing (NSMHWB 2017). Although this survey used CIDI version 3.0 and slight variations in questions,31 the diagnoses were made according to DSM-IV, which did not change substantially over the versions. Person weights provided in the curf were applied to account for the ABS sampling strategy, to give accurate national population estimates. These estimates of prevalence were computed within each 5-year age band that was included within the curf (individual ages were not published, to preserve confidentiality) and then weighted by the number of sons and daughters within each age-sex stratum. Thus, each age stratum for each diagnosis was standardized to the age distributions of sons and daughters, and the expected number of cases computed. The ratio of obtained cases to expected cases was computed as the relative prevalence, and the associated 95% confidence intervals were computed using the Normal approximation to the Binomial, thus adjusting for age and sex,32 a strategy used for their mothers15 and veteran fathers.1,3 Bootstrap estimates of 95% confidence intervals of prevalence were computed for low prevalence outcomes (< 5%). The relationship of child PTSD to other mental health measures was assessed with odds ratios (ORs) and 95% confidence intervals (CIs). ORs were adjusted for potential confounders using multivariate logistic regression; these consisted of age and all of the remaining DSM-IV diagnoses where appropriate. Diagnoses were excluded based on collinearity or parameter stability: for example, alcohol dependence and alcohol abuse are mutually exclusive and thus adjusting for each other introduces a vector of zeros, and low prevalence disorders were excluded including dysthymia, obsessive-compulsive disorder, bipolar disorder and schizophrenia. The additional risk of each comorbid condition due to PTSD (attributable risk, AR)33 was computed from the regression-adjusted ORs. The AR indicates the additional disorder that may be attributable to PSTD. Results Subject recruitment There were 394 sons and 340 daughters whose contact address was available for mail-out invitations to participate. Response varied significantly by sex of child (χ24 = 31.556, P < 0.001); more sons (60.4%) than daughters (40.3%) failed to respond to communications, but similar numbers refused (3.8% each), or agreed but withdrew (0.7% and 0.9%, respectively), and agreed but were not interviewed for logistic reasons (1.5% and 1.8%, respectively). Interviews were conducted with 315 offspring (133 sons, 182 daughters). Child response was not associated with veteran PTSD status or any psychiatric diagnosis except alcohol abuse/dependence [OR (95% CI) = 0.57 (0.37, 0.87), P = 0.009], but was associated with larger family size, shorter Army career, and higher intelligence. Sons’ and daughters’ demographics The average age at interview was similar for sons and daughters [mean (M) = 38.3 years, SD = 6.41, range 20–60, median 38.0] and all were Australian-born of mostly Caucasian parents. Most (86.5% of sons and 86.8% of daughters) were conceived after the veteran returned from Vietnam. Most (76.8%) left school aged 17 or 18, 75.5% completed high school finals and 79.4% of sons and 85.0% of daughters had gained some qualification after school, although the pattern of qualifications differed (χ2 = 3.779, df = 3, P < 0.001): 43.8% of sons and 47.1% of daughters had a university degree, 22.9% of sons and 2.5% of daughters had a trade and 29.5% of sons and 48.1% of daughters had a certificate or diploma qualification. Sons were more likely than daughters to have served in the Defence Forces (OR = 5.31, 95% CI = 2.21, 12.75). Most were currently employed, but sons had higher income levels (M = AU$89,891, SD = AU$53,119, median = AU$80,000) than daughters (M = AU$55,258, SD = AU$43,324, median = AU$48,500). About two-thirds held private health insurance (66.9% of sons and 67.6% of daughters) and home ownership did not differ between sons and daughters: 7.3% fully owned, 60.5% mortgaged, 23.2% were renting, 6.1% were staying with family or friends and 2.8% had other arrangements. Marital status was also similar between the sexes: 56.9% were married, 16.9% were cohabiting, 4.2% were separated, 4.8% were divorced, 0.3% were widowed and 16.9% were never married. When compared with the ABS ‘curf’, Table 1 shows that more sons and daughters completed Year 12 (final high school) and fewer dropped out beforehand than the rest of the population. More daughters were currently employed and fewer were not in the work force, but more sons and daughters were also unemployed than expected from population figures. More were married or cohabiting than population expectations and more sons and daughters had served in the ADF than the background Australian population. Table 1. Highest school class completed, employment and marital status, and service in Australian Defence Force (ADF) for sons and daughters, and relative prevalence (RP) and 95% confidence intervals (95% CI) compared with age-sex matched Australian population estimates. (Empty cells indicate low reliability of parameters due to small sample size) Sons Daughters Prevalence(%) RP 95%CI Prevalence(%) RP 95%CI Highest school class completed:  Year 12 71.4 1.53 1.36, 1.69 76.9 1.34 1.23, 1.45  Year 11 9.0 0.72 0.33, 1.11 6.6 0.49 0.22, 0.76  Year 10 15.8 0.63 0.38, 0.87 12.1 0.51 0.31, 0.71  Year 9 0.8 – – 3.9 1.00 0.27, 1.73  Year 8 or less 1.5 – – 0.6 – – Ever served in ADF 16.5 3.24 2.00, 4.48 4.4 3.35 1.08, 5.62 Employment status:  Employed 91.0 1.00 0.95, 1.06 81.9 1.15 1.08, 1.23  Unemployed 8.3 5.07 2.20, 7.94 15.9 6.96 4.64, 9.29  Not in work force 0.8 – – 2.2 – – Marital status:  Married/cohabiting 74.4 1.26 1.13, 1.38 73.6 1.24 1.13, 1.34  Separated 3.8 1.46 0.21, 2.72 4.4 1.72 0.56, 2.89  Divorced 3.8 0.63 0.09, 1.18 5.5 0.97 0.38, 1.55  Widowed 0.8 – – 0.5 – –  Never married 17.3 0.70 0.44, 0.98 16.5 0.68 0.46, 0.91 Sons Daughters Prevalence(%) RP 95%CI Prevalence(%) RP 95%CI Highest school class completed:  Year 12 71.4 1.53 1.36, 1.69 76.9 1.34 1.23, 1.45  Year 11 9.0 0.72 0.33, 1.11 6.6 0.49 0.22, 0.76  Year 10 15.8 0.63 0.38, 0.87 12.1 0.51 0.31, 0.71  Year 9 0.8 – – 3.9 1.00 0.27, 1.73  Year 8 or less 1.5 – – 0.6 – – Ever served in ADF 16.5 3.24 2.00, 4.48 4.4 3.35 1.08, 5.62 Employment status:  Employed 91.0 1.00 0.95, 1.06 81.9 1.15 1.08, 1.23  Unemployed 8.3 5.07 2.20, 7.94 15.9 6.96 4.64, 9.29  Not in work force 0.8 – – 2.2 – – Marital status:  Married/cohabiting 74.4 1.26 1.13, 1.38 73.6 1.24 1.13, 1.34  Separated 3.8 1.46 0.21, 2.72 4.4 1.72 0.56, 2.89  Divorced 3.8 0.63 0.09, 1.18 5.5 0.97 0.38, 1.55  Widowed 0.8 – – 0.5 – –  Never married 17.3 0.70 0.44, 0.98 16.5 0.68 0.46, 0.91 Table 1. Highest school class completed, employment and marital status, and service in Australian Defence Force (ADF) for sons and daughters, and relative prevalence (RP) and 95% confidence intervals (95% CI) compared with age-sex matched Australian population estimates. (Empty cells indicate low reliability of parameters due to small sample size) Sons Daughters Prevalence(%) RP 95%CI Prevalence(%) RP 95%CI Highest school class completed:  Year 12 71.4 1.53 1.36, 1.69 76.9 1.34 1.23, 1.45  Year 11 9.0 0.72 0.33, 1.11 6.6 0.49 0.22, 0.76  Year 10 15.8 0.63 0.38, 0.87 12.1 0.51 0.31, 0.71  Year 9 0.8 – – 3.9 1.00 0.27, 1.73  Year 8 or less 1.5 – – 0.6 – – Ever served in ADF 16.5 3.24 2.00, 4.48 4.4 3.35 1.08, 5.62 Employment status:  Employed 91.0 1.00 0.95, 1.06 81.9 1.15 1.08, 1.23  Unemployed 8.3 5.07 2.20, 7.94 15.9 6.96 4.64, 9.29  Not in work force 0.8 – – 2.2 – – Marital status:  Married/cohabiting 74.4 1.26 1.13, 1.38 73.6 1.24 1.13, 1.34  Separated 3.8 1.46 0.21, 2.72 4.4 1.72 0.56, 2.89  Divorced 3.8 0.63 0.09, 1.18 5.5 0.97 0.38, 1.55  Widowed 0.8 – – 0.5 – –  Never married 17.3 0.70 0.44, 0.98 16.5 0.68 0.46, 0.91 Sons Daughters Prevalence(%) RP 95%CI Prevalence(%) RP 95%CI Highest school class completed:  Year 12 71.4 1.53 1.36, 1.69 76.9 1.34 1.23, 1.45  Year 11 9.0 0.72 0.33, 1.11 6.6 0.49 0.22, 0.76  Year 10 15.8 0.63 0.38, 0.87 12.1 0.51 0.31, 0.71  Year 9 0.8 – – 3.9 1.00 0.27, 1.73  Year 8 or less 1.5 – – 0.6 – – Ever served in ADF 16.5 3.24 2.00, 4.48 4.4 3.35 1.08, 5.62 Employment status:  Employed 91.0 1.00 0.95, 1.06 81.9 1.15 1.08, 1.23  Unemployed 8.3 5.07 2.20, 7.94 15.9 6.96 4.64, 9.29  Not in work force 0.8 – – 2.2 – – Marital status:  Married/cohabiting 74.4 1.26 1.13, 1.38 73.6 1.24 1.13, 1.34  Separated 3.8 1.46 0.21, 2.72 4.4 1.72 0.56, 2.89  Divorced 3.8 0.63 0.09, 1.18 5.5 0.97 0.38, 1.55  Widowed 0.8 – – 0.5 – –  Never married 17.3 0.70 0.44, 0.98 16.5 0.68 0.46, 0.91 Trauma exposure Table 2 shows the prevalence of each potentially traumatic event as personally experienced and the relative prevalence compared with the Australian population. Both sons and daughters reported experiencing more exposures to natural disasters, fire or explosion and transport accidents, whereas sons reported more exposures to toxic chemicals at work and daughters reported more sexual assault. More than one in 10 daughters reported actual rape, but sadly this was not different from the age-matched Australian contemporaneous female population. Table 2. Prevalence of traumatic events reported by sons and daughters, the relative prevalence (RP) and 95% confidence intervals (95% CI) compared with the age-sex matched Australian population, and the odds ratio (OR) and 95% confidence interval for the association of each traumatic event with PTSD in sons and daughters. (Empty cells indicate low reliability of parameters due to small sample size.) Sons(n = 133) Daughters(n = 182) Population comparison Sons PTSD Population comparison Daughters PSTD Prevalence (%) RP 95% CI OR 95% CI Prevalence (%) RP 95% CI OR 95%CI Natural disaster 30.1 3.10 2.29, 3.90 1.43 0.32, 6.28 29.1 3.92 3.03, 4.81 0.74 0.32, 1.69 Fire, explosion 20.3 3.60 2.39, 4.82 7.80 1.74,35.10 14.3 4.91 3.16, 6.65 0.68 0.22, 2.10 Transport accident 50.4 2.91 2.42, 3.40 3.15 0.61, 16.20 45.6 5.34 4.49, 6.18 2.69 1.27, 5.71 Exposure to toxic chemicals 15.0 2.15 1.28, 3.01 1.32 1.09, 1.60 6.0 2.18 0.93, 3.42 3.15 1.11, 8.95 Assault with weapon 20.3 1.14 0.76, 1.53 7.80 1.74, 35.10 14.8 1.53 1.00, 2.06 0.83 0.22, 3.04 Rape 0.8 – – 5.62 0.96, 33.08 11.5 1.15 0.69, 1.61 15.68 6.67, 36.8 Other sexual assault 6.8 1.34 0.50, 2.19 4.30 0.76, 24.43 24.7 1.35 1.01, 1.69 4.41 2.05, 9.48 Captivity 3.0 2.31 0.08, 4.53 (No cases with PTSD) 0.6 – – (No cases without PTSD) Life-threatening illness 9.8 1.47 0.71, 2.23 6.90 1.44, 33.18 9.3 1.28 0.70, 1.86 2.36 0.81, 8.65 Cause injury/death to another 5.3 2.92 0.82, 5.03 18.15 3.17, 103.80 2.2 3.64 0.11, 7.16 4.09 0.56, 30.02 Unexpected close death 22.6 0.67 0.46, 0.88 1.16 0.22, 6.04 31.3 0.88 0.69, 1.07 1.67 0.79, 3.53 Sons(n = 133) Daughters(n = 182) Population comparison Sons PTSD Population comparison Daughters PSTD Prevalence (%) RP 95% CI OR 95% CI Prevalence (%) RP 95% CI OR 95%CI Natural disaster 30.1 3.10 2.29, 3.90 1.43 0.32, 6.28 29.1 3.92 3.03, 4.81 0.74 0.32, 1.69 Fire, explosion 20.3 3.60 2.39, 4.82 7.80 1.74,35.10 14.3 4.91 3.16, 6.65 0.68 0.22, 2.10 Transport accident 50.4 2.91 2.42, 3.40 3.15 0.61, 16.20 45.6 5.34 4.49, 6.18 2.69 1.27, 5.71 Exposure to toxic chemicals 15.0 2.15 1.28, 3.01 1.32 1.09, 1.60 6.0 2.18 0.93, 3.42 3.15 1.11, 8.95 Assault with weapon 20.3 1.14 0.76, 1.53 7.80 1.74, 35.10 14.8 1.53 1.00, 2.06 0.83 0.22, 3.04 Rape 0.8 – – 5.62 0.96, 33.08 11.5 1.15 0.69, 1.61 15.68 6.67, 36.8 Other sexual assault 6.8 1.34 0.50, 2.19 4.30 0.76, 24.43 24.7 1.35 1.01, 1.69 4.41 2.05, 9.48 Captivity 3.0 2.31 0.08, 4.53 (No cases with PTSD) 0.6 – – (No cases without PTSD) Life-threatening illness 9.8 1.47 0.71, 2.23 6.90 1.44, 33.18 9.3 1.28 0.70, 1.86 2.36 0.81, 8.65 Cause injury/death to another 5.3 2.92 0.82, 5.03 18.15 3.17, 103.80 2.2 3.64 0.11, 7.16 4.09 0.56, 30.02 Unexpected close death 22.6 0.67 0.46, 0.88 1.16 0.22, 6.04 31.3 0.88 0.69, 1.07 1.67 0.79, 3.53 Table 2. Prevalence of traumatic events reported by sons and daughters, the relative prevalence (RP) and 95% confidence intervals (95% CI) compared with the age-sex matched Australian population, and the odds ratio (OR) and 95% confidence interval for the association of each traumatic event with PTSD in sons and daughters. (Empty cells indicate low reliability of parameters due to small sample size.) Sons(n = 133) Daughters(n = 182) Population comparison Sons PTSD Population comparison Daughters PSTD Prevalence (%) RP 95% CI OR 95% CI Prevalence (%) RP 95% CI OR 95%CI Natural disaster 30.1 3.10 2.29, 3.90 1.43 0.32, 6.28 29.1 3.92 3.03, 4.81 0.74 0.32, 1.69 Fire, explosion 20.3 3.60 2.39, 4.82 7.80 1.74,35.10 14.3 4.91 3.16, 6.65 0.68 0.22, 2.10 Transport accident 50.4 2.91 2.42, 3.40 3.15 0.61, 16.20 45.6 5.34 4.49, 6.18 2.69 1.27, 5.71 Exposure to toxic chemicals 15.0 2.15 1.28, 3.01 1.32 1.09, 1.60 6.0 2.18 0.93, 3.42 3.15 1.11, 8.95 Assault with weapon 20.3 1.14 0.76, 1.53 7.80 1.74, 35.10 14.8 1.53 1.00, 2.06 0.83 0.22, 3.04 Rape 0.8 – – 5.62 0.96, 33.08 11.5 1.15 0.69, 1.61 15.68 6.67, 36.8 Other sexual assault 6.8 1.34 0.50, 2.19 4.30 0.76, 24.43 24.7 1.35 1.01, 1.69 4.41 2.05, 9.48 Captivity 3.0 2.31 0.08, 4.53 (No cases with PTSD) 0.6 – – (No cases without PTSD) Life-threatening illness 9.8 1.47 0.71, 2.23 6.90 1.44, 33.18 9.3 1.28 0.70, 1.86 2.36 0.81, 8.65 Cause injury/death to another 5.3 2.92 0.82, 5.03 18.15 3.17, 103.80 2.2 3.64 0.11, 7.16 4.09 0.56, 30.02 Unexpected close death 22.6 0.67 0.46, 0.88 1.16 0.22, 6.04 31.3 0.88 0.69, 1.07 1.67 0.79, 3.53 Sons(n = 133) Daughters(n = 182) Population comparison Sons PTSD Population comparison Daughters PSTD Prevalence (%) RP 95% CI OR 95% CI Prevalence (%) RP 95% CI OR 95%CI Natural disaster 30.1 3.10 2.29, 3.90 1.43 0.32, 6.28 29.1 3.92 3.03, 4.81 0.74 0.32, 1.69 Fire, explosion 20.3 3.60 2.39, 4.82 7.80 1.74,35.10 14.3 4.91 3.16, 6.65 0.68 0.22, 2.10 Transport accident 50.4 2.91 2.42, 3.40 3.15 0.61, 16.20 45.6 5.34 4.49, 6.18 2.69 1.27, 5.71 Exposure to toxic chemicals 15.0 2.15 1.28, 3.01 1.32 1.09, 1.60 6.0 2.18 0.93, 3.42 3.15 1.11, 8.95 Assault with weapon 20.3 1.14 0.76, 1.53 7.80 1.74, 35.10 14.8 1.53 1.00, 2.06 0.83 0.22, 3.04 Rape 0.8 – – 5.62 0.96, 33.08 11.5 1.15 0.69, 1.61 15.68 6.67, 36.8 Other sexual assault 6.8 1.34 0.50, 2.19 4.30 0.76, 24.43 24.7 1.35 1.01, 1.69 4.41 2.05, 9.48 Captivity 3.0 2.31 0.08, 4.53 (No cases with PTSD) 0.6 – – (No cases without PTSD) Life-threatening illness 9.8 1.47 0.71, 2.23 6.90 1.44, 33.18 9.3 1.28 0.70, 1.86 2.36 0.81, 8.65 Cause injury/death to another 5.3 2.92 0.82, 5.03 18.15 3.17, 103.80 2.2 3.64 0.11, 7.16 4.09 0.56, 30.02 Unexpected close death 22.6 0.67 0.46, 0.88 1.16 0.22, 6.04 31.3 0.88 0.69, 1.07 1.67 0.79, 3.53 Sons and daughters reported a similar number of trauma exposures (M = 3.13, SD = 2.42; M = 2.72, SD = 2.10; respectively, for sons and daughters; t313 = 1.592, P = 0.112) but differed in the types of trauma experienced. Sons were more likely than daughters to experience a serious work accident [OR = 3.11, 95% CI (1.64, 5.85)], exposure to toxic chemicals [OR = 2.96, 95% CI (1.33, 6.53)], a physical assault [OR = 2.97, 95% CI (1.86, 4.76)] and assault with a weapon [OR = 2.56, 95% CI (1.32, 4.98)], whereas daughters were more likely to experience rape [OR = 8.31, 95% CI (1.91, 36.21)], sexual assault [OR = 3.92, 95% CI (1.89, 8.14)] and unwanted sexual experiences [OR = 3.32, 95% CI (1.67, 6.57)]. Table 2 also shows the odds ratios and 95% confidence intervals for the association of each potentially traumatic exposure with sons’ and daughters’ PTSD. Although sons had higher risk of exposure to natural disasters and transport accidents, these were not traumagenic; however exposure to fires/explosions and toxic chemicals were also associated with PTSD. Daughters also were at higher risk of natural disasters, fires and transport accidents than the population, but only accidents were traumagenic; rape and sexual assault bore higher risks for PTSD and sexual assaults were more common than in the background population. Further analysis revealed that 66.6% of daughters who reported rape reported that this was their ‘worst’ event, of whom 75% were diagnosed with PTSD, and 53.1% of those reporting sexual abuse reported this as their ‘worst’ event, of whom 19.2% were diagnosed with PTSD. Mental health Table 3 shows the prevalence of lifetime DSM-IV diagnoses among sons and daughters and the relative prevalence and 95% confidence intervals compared with the contemporaneous Australian population. For sons, there were higher than expected prevalences of alcohol dependence, drug abuse and dependence and major depression, whereas daughters experienced higher prevalence of alcohol abuse and dependence, drug abuse and dependence and major depressive disorders; daughters (but not sons) also experienced more PTSD and more generalized anxiety disorder than expected. Table 3. Prevalence of DSM-IV psychiatric diagnoses in sons and daughters of Australian Vietnam veterans and relative prevalence (RP) and 95% confidence intervals (95% CI) compared with the age-sex matched Australian population Sons Daughters Prevalence (%) RP 95% CI Prevalence (%) RP 95% CI Alcohol dependence 19.6 3.17 2.07, 4.26 12.1 3.50 2.13, 4.88 Alcohol abuse 21.8 0.80 0.54, 1.05 18.7 1.65 1.15, 2.15 Any drug dependence 12.0 2.41 1.30, 3.52 8.2 3.11 1.60, 4.62 Any drug abuse 18.8 2.27 1.47, 3.07 10.4 2.64 1.52, 3.76 Cannabis dependence 12.0 3.03 1.64, 4.42 3.3 2.44 0.52, 4.37 Cannabis abuse 13.5 1.81 1.03, 2.58 7.7 1.99 0.99, 2.98 Major depression 24.8 1.70 1.20, 2.21 42.3 1.92 1.59, 2.24 Dysthymic disorder 1.5 0.91 0.00, 2.36 1.7 0.76 0.00, 1.76 PTSD 6.0 0.89 0.29, 1.48 20.3 1.55 1.10, 2.00 Agoraphobia 1.5 0.97 0.00, 2.59 6.0 1.54 0.66, 2.43 Panic without agoraphobia 2.3 0.69 0.00, 1.45 5.0 1.45 0.53, 2.38 Panic with agoraphobia 0.8 1.12 0.00, 5.98 3.3 2.10 0.45, 3.76 Agoraphobia without panic 0.8 0.86 0.00, 2.15 0.6 0.23 0.00, 0.72 Social phobia 4.5 0.56 0.12, 0.99 16.5 1.37 0.92, 1.82 Generalized anxiety disorder 12.8 1.47 0.82, 2.13 16.5 1.96 1.32, 2.60 Bipolar I disorder 3.8 4.26 0.60, 7.92 3.3 3.00 0.64, 5.36 Suicidality  Suicide thoughts 17.3 1.19 0.75, 1.63 16.5 0.68 0.46, 0.92  Suicide plan 4.5 1.32 0.29, 2.35 15.4 2.77 1.83, 3.72  Suicide attempt 3.0 1.08 0.04, 2.12 8.2 1.90 0.98, 2.83 Sons Daughters Prevalence (%) RP 95% CI Prevalence (%) RP 95% CI Alcohol dependence 19.6 3.17 2.07, 4.26 12.1 3.50 2.13, 4.88 Alcohol abuse 21.8 0.80 0.54, 1.05 18.7 1.65 1.15, 2.15 Any drug dependence 12.0 2.41 1.30, 3.52 8.2 3.11 1.60, 4.62 Any drug abuse 18.8 2.27 1.47, 3.07 10.4 2.64 1.52, 3.76 Cannabis dependence 12.0 3.03 1.64, 4.42 3.3 2.44 0.52, 4.37 Cannabis abuse 13.5 1.81 1.03, 2.58 7.7 1.99 0.99, 2.98 Major depression 24.8 1.70 1.20, 2.21 42.3 1.92 1.59, 2.24 Dysthymic disorder 1.5 0.91 0.00, 2.36 1.7 0.76 0.00, 1.76 PTSD 6.0 0.89 0.29, 1.48 20.3 1.55 1.10, 2.00 Agoraphobia 1.5 0.97 0.00, 2.59 6.0 1.54 0.66, 2.43 Panic without agoraphobia 2.3 0.69 0.00, 1.45 5.0 1.45 0.53, 2.38 Panic with agoraphobia 0.8 1.12 0.00, 5.98 3.3 2.10 0.45, 3.76 Agoraphobia without panic 0.8 0.86 0.00, 2.15 0.6 0.23 0.00, 0.72 Social phobia 4.5 0.56 0.12, 0.99 16.5 1.37 0.92, 1.82 Generalized anxiety disorder 12.8 1.47 0.82, 2.13 16.5 1.96 1.32, 2.60 Bipolar I disorder 3.8 4.26 0.60, 7.92 3.3 3.00 0.64, 5.36 Suicidality  Suicide thoughts 17.3 1.19 0.75, 1.63 16.5 0.68 0.46, 0.92  Suicide plan 4.5 1.32 0.29, 2.35 15.4 2.77 1.83, 3.72  Suicide attempt 3.0 1.08 0.04, 2.12 8.2 1.90 0.98, 2.83 Table 3. Prevalence of DSM-IV psychiatric diagnoses in sons and daughters of Australian Vietnam veterans and relative prevalence (RP) and 95% confidence intervals (95% CI) compared with the age-sex matched Australian population Sons Daughters Prevalence (%) RP 95% CI Prevalence (%) RP 95% CI Alcohol dependence 19.6 3.17 2.07, 4.26 12.1 3.50 2.13, 4.88 Alcohol abuse 21.8 0.80 0.54, 1.05 18.7 1.65 1.15, 2.15 Any drug dependence 12.0 2.41 1.30, 3.52 8.2 3.11 1.60, 4.62 Any drug abuse 18.8 2.27 1.47, 3.07 10.4 2.64 1.52, 3.76 Cannabis dependence 12.0 3.03 1.64, 4.42 3.3 2.44 0.52, 4.37 Cannabis abuse 13.5 1.81 1.03, 2.58 7.7 1.99 0.99, 2.98 Major depression 24.8 1.70 1.20, 2.21 42.3 1.92 1.59, 2.24 Dysthymic disorder 1.5 0.91 0.00, 2.36 1.7 0.76 0.00, 1.76 PTSD 6.0 0.89 0.29, 1.48 20.3 1.55 1.10, 2.00 Agoraphobia 1.5 0.97 0.00, 2.59 6.0 1.54 0.66, 2.43 Panic without agoraphobia 2.3 0.69 0.00, 1.45 5.0 1.45 0.53, 2.38 Panic with agoraphobia 0.8 1.12 0.00, 5.98 3.3 2.10 0.45, 3.76 Agoraphobia without panic 0.8 0.86 0.00, 2.15 0.6 0.23 0.00, 0.72 Social phobia 4.5 0.56 0.12, 0.99 16.5 1.37 0.92, 1.82 Generalized anxiety disorder 12.8 1.47 0.82, 2.13 16.5 1.96 1.32, 2.60 Bipolar I disorder 3.8 4.26 0.60, 7.92 3.3 3.00 0.64, 5.36 Suicidality  Suicide thoughts 17.3 1.19 0.75, 1.63 16.5 0.68 0.46, 0.92  Suicide plan 4.5 1.32 0.29, 2.35 15.4 2.77 1.83, 3.72  Suicide attempt 3.0 1.08 0.04, 2.12 8.2 1.90 0.98, 2.83 Sons Daughters Prevalence (%) RP 95% CI Prevalence (%) RP 95% CI Alcohol dependence 19.6 3.17 2.07, 4.26 12.1 3.50 2.13, 4.88 Alcohol abuse 21.8 0.80 0.54, 1.05 18.7 1.65 1.15, 2.15 Any drug dependence 12.0 2.41 1.30, 3.52 8.2 3.11 1.60, 4.62 Any drug abuse 18.8 2.27 1.47, 3.07 10.4 2.64 1.52, 3.76 Cannabis dependence 12.0 3.03 1.64, 4.42 3.3 2.44 0.52, 4.37 Cannabis abuse 13.5 1.81 1.03, 2.58 7.7 1.99 0.99, 2.98 Major depression 24.8 1.70 1.20, 2.21 42.3 1.92 1.59, 2.24 Dysthymic disorder 1.5 0.91 0.00, 2.36 1.7 0.76 0.00, 1.76 PTSD 6.0 0.89 0.29, 1.48 20.3 1.55 1.10, 2.00 Agoraphobia 1.5 0.97 0.00, 2.59 6.0 1.54 0.66, 2.43 Panic without agoraphobia 2.3 0.69 0.00, 1.45 5.0 1.45 0.53, 2.38 Panic with agoraphobia 0.8 1.12 0.00, 5.98 3.3 2.10 0.45, 3.76 Agoraphobia without panic 0.8 0.86 0.00, 2.15 0.6 0.23 0.00, 0.72 Social phobia 4.5 0.56 0.12, 0.99 16.5 1.37 0.92, 1.82 Generalized anxiety disorder 12.8 1.47 0.82, 2.13 16.5 1.96 1.32, 2.60 Bipolar I disorder 3.8 4.26 0.60, 7.92 3.3 3.00 0.64, 5.36 Suicidality  Suicide thoughts 17.3 1.19 0.75, 1.63 16.5 0.68 0.46, 0.92  Suicide plan 4.5 1.32 0.29, 2.35 15.4 2.77 1.83, 3.72  Suicide attempt 3.0 1.08 0.04, 2.12 8.2 1.90 0.98, 2.83 There were only few differences between the sexes in the prevalence of DSM-IV diagnoses: sons were more likely to be cannabis dependent than daughters (OR = 4.02, 95% CI = 1.52, 10.52; P = 0.003), but social phobia was more prevalent among daughters (OR = 2.22, 95% CI = 1.15, 7.39; P = 0.033), as was depression (OR = 2.22, 95% CI = 1.36, 3.63; P = 0.002), particularly recurrent depression (OR = 4.41, 95% CI = 2.14, 9.09; P < .001). There were no differences in the prevalence of any disorder between sons and daughters conceived after the veteran’s return and those born before his deployment. Suicidality among sons was not different from population expectations; however, among daughters there was less suicidal ideation but more planning; for both sons and daughters there was no increase in attempts compared with population expectations. Daughters had higher levels of suicidal ideation than sons (OR = 3.53, 95% CI = 1.41, 8.84; P = 0.005) and higher prevalence of planning (OR = 4.62, 95% CI = 1.02, 21.02; P = 0.030) but no difference in the rate of attempts (OR = 3.73, 95% CI = 0.043, 32.30; P = 0.201). Children’s PTSD and mental health Table 4 shows the adjusted odds ratios and 95% confidence intervals for comorbidity with children’s PTSD, and the attributable risk31 (AR) associated with PTSD. Among sons, PTSD was associated with drug abuse and dependence, particularly cannabis dependence. For sons, the AR was very low only for alcohol and cannabis abuse; highest ARs occurred for drug and cannabis dependence. For daughters, their lower risk of alcohol abuse was counterbalanced by a higher risk of dependence, for which more than two-thirds can be attributed to PTSD. This suggests that daughters with PTSD avoid alcohol abuse and more readily descend into dependence. Among daughters, PTSD was associated with alcohol, drug and cannabis dependence, major depressive disorder, social phobia, generaliszd anxiety and bipolar I disorders. Cannabis and drug dependence seem also highly associated with PTSD, and PTSD was associated with more than three-quarters of the cases of depression, more than half the cases of anxiety and 70% of the cases of alcohol dependence, all of which were in excess of proportions in the general population. Table 4. Adjusted odds ratios (OR) and 95% confidence intervals (CI) for comorbidity of DSM-IV psychiatric diagnoses with PTSD in sons and daughters of Australian Vietnam veterans, and the attributable risk (AR) of comorbidity associated with PTSD Sons Daughters OR 95% CI AR(%) OR 95% CI AR(%) Alcohol dependence 1.89 0.38, 9.31 47.12 3.29 1.17, 9.30 69.60 Alcohol abuse 1.03 0.41, 2.61 3.19 1.02 0.41, 2.57 1.96 Any drug dependence 37.03 6.47, 211.80 97.30 4.60 1.37, 15.45 78.28 Any drug abuse 11.41 2.36, 55.17 91.24 1.97 0.69, 5.58 49.11 Cannabis dependence 33.61 5.96, 189.53 97.02 12.47 1.27, 122.39 91.98 Cannabis abuse 1.09 0.12, 9.90 8.26 1.64 0.48, 5.54 39.02 Major depression 1.38 0.29, 6.70 52.49 4.45 1.94, 10.23 77.55 Social phobia 3.35 0.34, 32.90 70.13 3.56 1.30, 9.74 71.89 Generalized anxiety disorder 5.02 0.94, 26.72 80.08 2.15 0.87, 5.34 53.55 Suicide thoughts 10.62 1.10, 103.09 90.59 3.68 1.51, 8.88 72.83 Suicide plan 7.71 1.00, 313.83 87.03 3.08 0.92, 10.33 67.53 Sons Daughters OR 95% CI AR(%) OR 95% CI AR(%) Alcohol dependence 1.89 0.38, 9.31 47.12 3.29 1.17, 9.30 69.60 Alcohol abuse 1.03 0.41, 2.61 3.19 1.02 0.41, 2.57 1.96 Any drug dependence 37.03 6.47, 211.80 97.30 4.60 1.37, 15.45 78.28 Any drug abuse 11.41 2.36, 55.17 91.24 1.97 0.69, 5.58 49.11 Cannabis dependence 33.61 5.96, 189.53 97.02 12.47 1.27, 122.39 91.98 Cannabis abuse 1.09 0.12, 9.90 8.26 1.64 0.48, 5.54 39.02 Major depression 1.38 0.29, 6.70 52.49 4.45 1.94, 10.23 77.55 Social phobia 3.35 0.34, 32.90 70.13 3.56 1.30, 9.74 71.89 Generalized anxiety disorder 5.02 0.94, 26.72 80.08 2.15 0.87, 5.34 53.55 Suicide thoughts 10.62 1.10, 103.09 90.59 3.68 1.51, 8.88 72.83 Suicide plan 7.71 1.00, 313.83 87.03 3.08 0.92, 10.33 67.53 Dysthymia, panic with agoraphobia, agoraphobia without panic, bipolar I and suicide attempt omitted due to small prevalence. Table 4. Adjusted odds ratios (OR) and 95% confidence intervals (CI) for comorbidity of DSM-IV psychiatric diagnoses with PTSD in sons and daughters of Australian Vietnam veterans, and the attributable risk (AR) of comorbidity associated with PTSD Sons Daughters OR 95% CI AR(%) OR 95% CI AR(%) Alcohol dependence 1.89 0.38, 9.31 47.12 3.29 1.17, 9.30 69.60 Alcohol abuse 1.03 0.41, 2.61 3.19 1.02 0.41, 2.57 1.96 Any drug dependence 37.03 6.47, 211.80 97.30 4.60 1.37, 15.45 78.28 Any drug abuse 11.41 2.36, 55.17 91.24 1.97 0.69, 5.58 49.11 Cannabis dependence 33.61 5.96, 189.53 97.02 12.47 1.27, 122.39 91.98 Cannabis abuse 1.09 0.12, 9.90 8.26 1.64 0.48, 5.54 39.02 Major depression 1.38 0.29, 6.70 52.49 4.45 1.94, 10.23 77.55 Social phobia 3.35 0.34, 32.90 70.13 3.56 1.30, 9.74 71.89 Generalized anxiety disorder 5.02 0.94, 26.72 80.08 2.15 0.87, 5.34 53.55 Suicide thoughts 10.62 1.10, 103.09 90.59 3.68 1.51, 8.88 72.83 Suicide plan 7.71 1.00, 313.83 87.03 3.08 0.92, 10.33 67.53 Sons Daughters OR 95% CI AR(%) OR 95% CI AR(%) Alcohol dependence 1.89 0.38, 9.31 47.12 3.29 1.17, 9.30 69.60 Alcohol abuse 1.03 0.41, 2.61 3.19 1.02 0.41, 2.57 1.96 Any drug dependence 37.03 6.47, 211.80 97.30 4.60 1.37, 15.45 78.28 Any drug abuse 11.41 2.36, 55.17 91.24 1.97 0.69, 5.58 49.11 Cannabis dependence 33.61 5.96, 189.53 97.02 12.47 1.27, 122.39 91.98 Cannabis abuse 1.09 0.12, 9.90 8.26 1.64 0.48, 5.54 39.02 Major depression 1.38 0.29, 6.70 52.49 4.45 1.94, 10.23 77.55 Social phobia 3.35 0.34, 32.90 70.13 3.56 1.30, 9.74 71.89 Generalized anxiety disorder 5.02 0.94, 26.72 80.08 2.15 0.87, 5.34 53.55 Suicide thoughts 10.62 1.10, 103.09 90.59 3.68 1.51, 8.88 72.83 Suicide plan 7.71 1.00, 313.83 87.03 3.08 0.92, 10.33 67.53 Dysthymia, panic with agoraphobia, agoraphobia without panic, bipolar I and suicide attempt omitted due to small prevalence. Suicidal ideation was associated with PTSD for both sons and daughters, with high ARs. Among sons there was no suicide attempt without PTSD, whereas among daughters there was no attempt with PTSD. These findings contrast with the PTSD-suicidality relationships displayed by their parents16 where ideation, planning and attempts were all higher than population expectations and all related to PTSD. Discussion This study has observed higher rates of some mental health problems among the sons and daughters of Australian Vietnam veterans than expected, based on similar age-sex matched information from the Australian population. It has also shown that veterans’ children were at higher risk of exposure to some potential traumas and have higher risk of PTSD than their peers in the general population. Although more highly educated, from more stable personal family environments and with better employment, veterans’ adult children appear to be at higher risk of alcohol and other substance use disorders and depressive disorders than expected. Daughters appear more prone to trauma exposures and consequent PTSD. The higher rates of sexual assault reported by daughters carried a higher rate of PTSD than seen in the Australian population and, although there was not more rape reported among daughters, the results reinforce the high level of traumagenicity associated with this type of experience. PTSD also carries significant comorbidity and increases the risk of disorders throughout the mental health realm, from depression and social phobia to alcohol, cannabis and drug dependence. Of concern are the findings in suicidality, both more prevalent in sons and daughters than population expectations and associated with PTSD. War service has ripple effects in families of combat veterans, where PTSD in veterans, who themselves have higher risk of alcohol misuse, depression and PTSD,3 increases the risk of PTSD in his children without necessarily increasing the risk of exposure to traumas,20 and alcohol disorders similarly increase the risk of alcohol disorders in their children.20 This increased risk in children is borne out here by the higher rates of alcohol disorder and PTSD. PTSD is accompanied by significant comorbidity, especially depression, anxiety and substance use disorders, consistent with the higher rates of these disorders in daughters and sons and the proportion that may be attributable to PTSD. Strengths and weaknesses Comparison of subpopulations with their ‘official’ parent populations is a means of making inferences about the health of a subgroup exposed to some factor in the absence of a dedicated control group that are not so exposed, but is not without uncertainties.27 Sons’ and daughters’ response rates were less than ideal (as was the ABS NSMHWB-07 that itself registered a response rate of only 60%). In particular, intelligence is itself a risk factor for PTSD, and the non-response analysis performed showed that the respondents had veteran fathers who were higher in intelligence; this suggests that the non-responders conceal veterans and offspring who may have higher rates of PTSD than observed here. Moreover, although the WHO CIDI has been reported to have high concordance with clinical diagnoses,34 it has been reported to underestimate PTSD rates in female US Vietnam-era veterans when compared with the CAPS.35 The NSMHWB 2007 PTSD module also included more potentially traumatic events than the CAPS, which may have increased the prevalence of PTSD in the 2007 ABS survey.31 However, for reasons of interview duration reduction, the ABS CIDI format did not include the three ‘worst’ events that were standard in previous versions of the CIDI and were structurally part of the CAPS interview. This is important, since eight of the 17 PTSD symptoms were referent to specific traumatic events, which also may have served to underestimate the prevalence of PTSD in the NSMHWB 2007. Although similar in many respects, the pattern of differences between the sexes may reflect a lack of generalizability to the greater population of sons, although many sex differences are cogent, such as the pattern of trauma exposures and related traumagenicity, the patterns of education particularly post-high school, income disparity and the higher risk of PTSD and depression among daughters. The question of generalizability to non-former military families is tempered by the demographic, trauma and mental health status of the sample of sons and daughters reported here. In addition, whereas the assessment instruments are highly structured, lack of funding and the wide geographical distribution of subjects rendered establishment of reliability via re-interview infeasible. Moreover, all interviewers were graduate-level researchers, which would not characterize ABS professional lay interviewers. Strengths of the study are its design as a nested study within the veterans’ cohort study, its use of standardized assessment measures and assessment by masters- or doctoral-level clinicians and researchers, likely not to be in the interviewing workforce of the ABS. This may have made the assessments more sensitive, as is intended with the administration of the CAPS, although the CIDI is highly structured and more resistant to interviewer effects. Whole-population estimates of the overall prevalence of PTSD are available, but comparisons with the present study may be misleading due to the different age structures in the published data. In the World Mental Health Surveys of trauma exposure36 and PTSD,37 the degree of traumatic exposure was not assessed in countries that have seen recent armed conflict, particularly in the Middle East and Africa; refugees were not included. These countries’ residents and refugees would be expected to display higher levels of trauma exposure and higher rates of PSTD. Even in developed countries with no recent non-terrorist related armed conflict, the degree of trauma exposure was reported to be of the order of 70%, yet the prevalence of PTSD was of the order of 4–6%. It may be predicted that an epidemic of trauma-related psychiatric problems is being generated by armed conflict, and this has the propensity to extend from the primary combatant into the next generation. Funding This work was supported by the Australian National Health and Medical Research Council (Grant Number 1011264). Conflict of interest: None declared. References 1 O'Toole BI , Marshall RP , Grayson DA et al. The Australian Vietnam Veterans Health Study. II. Self-reported health of veterans compared with the Australian population . Int J Epidemiol 1996 ; 25: 319 – 30 . 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The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium . Psychol Med 2016 ; 46: 327 – 43 . Google Scholar CrossRef Search ADS PubMed 37 Koenen KC, , Ratanatharathorn A, , Ng L et al. Posttraumatic stress disorder in the World Mental Health Surveys . Psychol Med 2017 ; 7 : 1 – 15 . © The Author(s) 2018; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Epidemiology Oxford University Press

The mental health of sons and daughters of Australian Vietnam veterans

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Oxford University Press
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© The Author(s) 2018; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association
ISSN
0300-5771
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1464-3685
D.O.I.
10.1093/ije/dyy010
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Abstract

Abstract Background War service increases the risk of post-traumatic stress disorder (PTSD) to combatants, and has been shown to increase the risk of PTSD in their offspring. The extent to which there is an excess compared with the general population is not yet established, nor whether PTSD increases the risk of other psychiatric problems. Methods A national sample of 133 sons and 182 daughters of a cohort of 179 Australian Vietnam veterans’ families were assessed in person, using structured psychiatric interviews. The prevalence of trauma exposures, DSM-IV (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition) diagnoses and suicidality were compared with the Australian Bureau of Statistics’ 2007 National Survey of Mental Health and Wellbeing data matched for age and sex. The risk of mental health problems potentially attributable to PTSD was also assessed. Results Sons and daughters were more likely than population expectations to report exposures to natural disasters, fire or explosions and transport accidents, and sons more likely to report exposure to toxic chemicals whereas daughters were more likely to report sexual assault. Sons and daughters had higher prevalences of alcohol and other substance dependence, depression and anxiety, and PTSD, and children’s PTSD was associated with substance dependence, depression and suicidal ideation. There were strong associations between children’s PTSD and comorbid conditions of substance use disorders, depression and anxiety. Conclusions Higher rates of mental health problems in veterans’ families, together with comorbidity with PTSD and the link between veterans’ and children’s PTSD, suggest that the effects of trauma may continue into subsequent generations. Epidemiology, PTSD, Vietnam veterans, offspring, intergenerational Key Messages Adult children of Australian Vietnam veterans are at higher risk of exposure to potential trauma and posttraumatic stress disorder than the background Australian population. Sons of veterans had higher risks for substance dependence and abuse, depression and suicidal ideation than expected, and daughters had higher risks for alcohol and drug dependence, depression, PTSD and generalized anxiety disorder than population expectations, and lower risk for suicidal ideation but higher risk for planning. PTSD in children is accompanied by significant comorbidity that is differentially distributed between sons and daughters, with daughters bearing significant comorbid alcohol, drug and cannabis dependence, depression, anxiety, social phobia and suicidal ideation. PTSD in war veterans transmissible to their children may have further attributable risks of psychiatric comorbidity in their children’s adulthood and has implications for an epidemic of post-conflict mental ill health in families in war-torn countries. Introduction War service and combat are known to be toxic to veterans’ post-war physical and mental health, particularly giving rise to post-traumatic stress disorder (PTSD),1–3 and may also be toxic to veterans’ families.4 Families of veterans often have to contend with conflict and rigidity in family functioning,5,6 and experience significant distress and relationship dysfunction,4 higher levels of carer burden on their partners and lower levels of marital adjustment and poorer parenting if the veteran has PTSD.7–9 PTSD in war veterans has been linked to increased risk of domestic violence,10–13 and psychiatric problems in their wives,5,14,15 and is strongly associated with suicidality in veterans and their wives.16 PTSD in a parent increases the risk of PTSD in their offspring,7–20 in what is termed intergenerational transmission of PTSD. This has been empirically demonstrated in Australian veterans’ families.20 Given that PTSD is more prevalent in veterans than the general civilian population, it might be expected that veterans’ children would also have higher prevalence of PTSD than the background population if their own risk of PTSD is enhanced by an intergenerational risk of PTSD. Moreover, PTSD may not be the only hazard in veterans’ children’s lives, since it is well established from studies of Vietnam21,22 that veterans also experience higher risks for other mental health problems such as substance use disorders such as alcohol dependence and abuse, as well as depression and anxiety.22 Since PTSD is known to be accompanied by significant comorbidity,23 it would also be expected that, if PTSD in a veteran parent increases the risk of PTSD in his children, then this should also be accompanied by a rise in the risk of other diagnoses such as depression and substance use disorders as comorbid companions of their own PTSD. We have already reported that veteran alcohol disorder was associated with increased risk of alcohol dependence and generalized anxiety in his sons, and alcohol and substance dependence, recurrent depression and social phobia in his daughters.20 Given veterans’ higher risk of alcohol disorders, this would imply an increased risk of these problems also in sons and daughters of the veterans. The degree to which PTSD in veterans’ children is responsible for any increased risk of comorbidity remains unknown, but if PTSD in a veteran father increases the risk of PTSD in his offspring, and those offspring also have concurrent comorbidity in addition to the background population risk, then this should also predict higher rates of mental health disorders in the population which are potentially attributable to this increased risk of PTSD. It is always possible that veterans’ active lifestyles and attraction to hazardous activities after service could increase the risk of his children’s exposure to potentially traumatic experiences. We have reported that PTSD in a veteran does not increase the risk of exposure to potentially traumatic events in daughters, and is only sporadically associated with traumatic events in sons, most of which were not traumagenic.20 However, it is not yet established whether veterans’ children have a higher risk of trauma exposure than would be found in the general background population. If sons and daughters have higher prevalence of exposures, then this might also predict higher rates of PTSD in sons and daughters irrespective of whether their father had PTSD. All of these considerations would lead to the hypotheses that there would be an increased risk of trauma exposure, increased risk of PTSD and increased risk of other mental health problems in veterans’ children compared with the general background population, but these are yet to be tested against empirical evidence. This study attempts to fill this gap in knowledge of the possible ripple effects of war service in veterans’ post-war families. The aims of the study were 3-fold: to establish the prevalence of exposure to trauma, DSM-IV ((Diagnostic and Statistical Manual of Mental Disorders Fourth Edition) mental health diagnoses and suicidality in sons and daughters of Australian Vietnam veterans; to compare these with contemporaneous age-sex matched Australian population data; and to explore the relationship of children’s PTSD to other mental health diagnoses and assess the attributable risk of mental health comorbidity due to PTSD. Methods This study is nested within a cohort study of Australian Vietnam veterans1–13,24 who had been posted to Vietnam during the 10-years of Australian involvement (1962-72). Veterans were personally assessed 22.0 years [standard deviation (SD) = 1.9] and 36.1 years (SD = 1.9) after return to Australia. Response bias assessment found that respondents at both waves had higher Army intelligence test scores and fewer absent without leave (AWOL) charges than non-respondents. The physical and mental health of the veterans, including psychiatric diagnoses and their relation to combat, have been presented previously from the first1,2,24 and second3 assessments. At the second assessment (2006-08), veterans’ adult children (aged 18+) were enumerated and veterans requested to provide their contact details. Of the 450 veterans interviewed, 352 (78.2%) gave consent to approach their child(ren), 55 (12.2%) refused and 43 (9.50%) denied having children. Veteran consent was not associated with veteran PTSD or any veteran psychiatric diagnosis except alcohol abuse/dependence [odds ratio (OR) (95% CI) = 0.48 (0.26, 0.83), P = 0.019]. Sons and daughters were interviewed in person at locations throughout Australia in the period July 2012–July 2014. PTSD was assessed using the Clinician-administered PTSD Scale (CAPS)25 for DSM-IV, and general psychiatric status was assessed with the Composite International Diagnostic Interview (CIDI version 2.1)26 for DSM-IV. The version of the CIDI was that used by the Australian Bureau of Statistics (ABS) in the Australian National Survey of Mental Health and Wellbeing 1997,27 which was also used for the veteran wave 2 interviews.3 Personality disorders were not included in the CIDI. The PTSD ‘A’ criterion of trauma exposure was established with a checklist of potentially traumatic exposures, such as natural disasters, assaults, accidents and other traumas. This preceded identification and recounting of their worst experiences, to establish the focal experiences for symptom assessment. In the CAPS, the symptom threshold criteria of frequency > 1 and intensity > 2 (F1-I2) was used for individual symptom significance.28,29 All interviewers in the studies were masters or doctoral-level clinical or research psychologists. All study subjects gave informed written consent before participation; the study received approval from the Human Research Ethics Committee of the University of Sydney (#14340). Statistical analysis Data analysis used SPSS V20.0.30 The lifetime prevalences in sons and daughters were compared with age-sex matched prevalences of diagnoses that were available from the ABS ‘confidentialised unit record file’ (curf) from the 2007 National Survey of Mental Health and Wellbeing (NSMHWB 2017). Although this survey used CIDI version 3.0 and slight variations in questions,31 the diagnoses were made according to DSM-IV, which did not change substantially over the versions. Person weights provided in the curf were applied to account for the ABS sampling strategy, to give accurate national population estimates. These estimates of prevalence were computed within each 5-year age band that was included within the curf (individual ages were not published, to preserve confidentiality) and then weighted by the number of sons and daughters within each age-sex stratum. Thus, each age stratum for each diagnosis was standardized to the age distributions of sons and daughters, and the expected number of cases computed. The ratio of obtained cases to expected cases was computed as the relative prevalence, and the associated 95% confidence intervals were computed using the Normal approximation to the Binomial, thus adjusting for age and sex,32 a strategy used for their mothers15 and veteran fathers.1,3 Bootstrap estimates of 95% confidence intervals of prevalence were computed for low prevalence outcomes (< 5%). The relationship of child PTSD to other mental health measures was assessed with odds ratios (ORs) and 95% confidence intervals (CIs). ORs were adjusted for potential confounders using multivariate logistic regression; these consisted of age and all of the remaining DSM-IV diagnoses where appropriate. Diagnoses were excluded based on collinearity or parameter stability: for example, alcohol dependence and alcohol abuse are mutually exclusive and thus adjusting for each other introduces a vector of zeros, and low prevalence disorders were excluded including dysthymia, obsessive-compulsive disorder, bipolar disorder and schizophrenia. The additional risk of each comorbid condition due to PTSD (attributable risk, AR)33 was computed from the regression-adjusted ORs. The AR indicates the additional disorder that may be attributable to PSTD. Results Subject recruitment There were 394 sons and 340 daughters whose contact address was available for mail-out invitations to participate. Response varied significantly by sex of child (χ24 = 31.556, P < 0.001); more sons (60.4%) than daughters (40.3%) failed to respond to communications, but similar numbers refused (3.8% each), or agreed but withdrew (0.7% and 0.9%, respectively), and agreed but were not interviewed for logistic reasons (1.5% and 1.8%, respectively). Interviews were conducted with 315 offspring (133 sons, 182 daughters). Child response was not associated with veteran PTSD status or any psychiatric diagnosis except alcohol abuse/dependence [OR (95% CI) = 0.57 (0.37, 0.87), P = 0.009], but was associated with larger family size, shorter Army career, and higher intelligence. Sons’ and daughters’ demographics The average age at interview was similar for sons and daughters [mean (M) = 38.3 years, SD = 6.41, range 20–60, median 38.0] and all were Australian-born of mostly Caucasian parents. Most (86.5% of sons and 86.8% of daughters) were conceived after the veteran returned from Vietnam. Most (76.8%) left school aged 17 or 18, 75.5% completed high school finals and 79.4% of sons and 85.0% of daughters had gained some qualification after school, although the pattern of qualifications differed (χ2 = 3.779, df = 3, P < 0.001): 43.8% of sons and 47.1% of daughters had a university degree, 22.9% of sons and 2.5% of daughters had a trade and 29.5% of sons and 48.1% of daughters had a certificate or diploma qualification. Sons were more likely than daughters to have served in the Defence Forces (OR = 5.31, 95% CI = 2.21, 12.75). Most were currently employed, but sons had higher income levels (M = AU$89,891, SD = AU$53,119, median = AU$80,000) than daughters (M = AU$55,258, SD = AU$43,324, median = AU$48,500). About two-thirds held private health insurance (66.9% of sons and 67.6% of daughters) and home ownership did not differ between sons and daughters: 7.3% fully owned, 60.5% mortgaged, 23.2% were renting, 6.1% were staying with family or friends and 2.8% had other arrangements. Marital status was also similar between the sexes: 56.9% were married, 16.9% were cohabiting, 4.2% were separated, 4.8% were divorced, 0.3% were widowed and 16.9% were never married. When compared with the ABS ‘curf’, Table 1 shows that more sons and daughters completed Year 12 (final high school) and fewer dropped out beforehand than the rest of the population. More daughters were currently employed and fewer were not in the work force, but more sons and daughters were also unemployed than expected from population figures. More were married or cohabiting than population expectations and more sons and daughters had served in the ADF than the background Australian population. Table 1. Highest school class completed, employment and marital status, and service in Australian Defence Force (ADF) for sons and daughters, and relative prevalence (RP) and 95% confidence intervals (95% CI) compared with age-sex matched Australian population estimates. (Empty cells indicate low reliability of parameters due to small sample size) Sons Daughters Prevalence(%) RP 95%CI Prevalence(%) RP 95%CI Highest school class completed:  Year 12 71.4 1.53 1.36, 1.69 76.9 1.34 1.23, 1.45  Year 11 9.0 0.72 0.33, 1.11 6.6 0.49 0.22, 0.76  Year 10 15.8 0.63 0.38, 0.87 12.1 0.51 0.31, 0.71  Year 9 0.8 – – 3.9 1.00 0.27, 1.73  Year 8 or less 1.5 – – 0.6 – – Ever served in ADF 16.5 3.24 2.00, 4.48 4.4 3.35 1.08, 5.62 Employment status:  Employed 91.0 1.00 0.95, 1.06 81.9 1.15 1.08, 1.23  Unemployed 8.3 5.07 2.20, 7.94 15.9 6.96 4.64, 9.29  Not in work force 0.8 – – 2.2 – – Marital status:  Married/cohabiting 74.4 1.26 1.13, 1.38 73.6 1.24 1.13, 1.34  Separated 3.8 1.46 0.21, 2.72 4.4 1.72 0.56, 2.89  Divorced 3.8 0.63 0.09, 1.18 5.5 0.97 0.38, 1.55  Widowed 0.8 – – 0.5 – –  Never married 17.3 0.70 0.44, 0.98 16.5 0.68 0.46, 0.91 Sons Daughters Prevalence(%) RP 95%CI Prevalence(%) RP 95%CI Highest school class completed:  Year 12 71.4 1.53 1.36, 1.69 76.9 1.34 1.23, 1.45  Year 11 9.0 0.72 0.33, 1.11 6.6 0.49 0.22, 0.76  Year 10 15.8 0.63 0.38, 0.87 12.1 0.51 0.31, 0.71  Year 9 0.8 – – 3.9 1.00 0.27, 1.73  Year 8 or less 1.5 – – 0.6 – – Ever served in ADF 16.5 3.24 2.00, 4.48 4.4 3.35 1.08, 5.62 Employment status:  Employed 91.0 1.00 0.95, 1.06 81.9 1.15 1.08, 1.23  Unemployed 8.3 5.07 2.20, 7.94 15.9 6.96 4.64, 9.29  Not in work force 0.8 – – 2.2 – – Marital status:  Married/cohabiting 74.4 1.26 1.13, 1.38 73.6 1.24 1.13, 1.34  Separated 3.8 1.46 0.21, 2.72 4.4 1.72 0.56, 2.89  Divorced 3.8 0.63 0.09, 1.18 5.5 0.97 0.38, 1.55  Widowed 0.8 – – 0.5 – –  Never married 17.3 0.70 0.44, 0.98 16.5 0.68 0.46, 0.91 Table 1. Highest school class completed, employment and marital status, and service in Australian Defence Force (ADF) for sons and daughters, and relative prevalence (RP) and 95% confidence intervals (95% CI) compared with age-sex matched Australian population estimates. (Empty cells indicate low reliability of parameters due to small sample size) Sons Daughters Prevalence(%) RP 95%CI Prevalence(%) RP 95%CI Highest school class completed:  Year 12 71.4 1.53 1.36, 1.69 76.9 1.34 1.23, 1.45  Year 11 9.0 0.72 0.33, 1.11 6.6 0.49 0.22, 0.76  Year 10 15.8 0.63 0.38, 0.87 12.1 0.51 0.31, 0.71  Year 9 0.8 – – 3.9 1.00 0.27, 1.73  Year 8 or less 1.5 – – 0.6 – – Ever served in ADF 16.5 3.24 2.00, 4.48 4.4 3.35 1.08, 5.62 Employment status:  Employed 91.0 1.00 0.95, 1.06 81.9 1.15 1.08, 1.23  Unemployed 8.3 5.07 2.20, 7.94 15.9 6.96 4.64, 9.29  Not in work force 0.8 – – 2.2 – – Marital status:  Married/cohabiting 74.4 1.26 1.13, 1.38 73.6 1.24 1.13, 1.34  Separated 3.8 1.46 0.21, 2.72 4.4 1.72 0.56, 2.89  Divorced 3.8 0.63 0.09, 1.18 5.5 0.97 0.38, 1.55  Widowed 0.8 – – 0.5 – –  Never married 17.3 0.70 0.44, 0.98 16.5 0.68 0.46, 0.91 Sons Daughters Prevalence(%) RP 95%CI Prevalence(%) RP 95%CI Highest school class completed:  Year 12 71.4 1.53 1.36, 1.69 76.9 1.34 1.23, 1.45  Year 11 9.0 0.72 0.33, 1.11 6.6 0.49 0.22, 0.76  Year 10 15.8 0.63 0.38, 0.87 12.1 0.51 0.31, 0.71  Year 9 0.8 – – 3.9 1.00 0.27, 1.73  Year 8 or less 1.5 – – 0.6 – – Ever served in ADF 16.5 3.24 2.00, 4.48 4.4 3.35 1.08, 5.62 Employment status:  Employed 91.0 1.00 0.95, 1.06 81.9 1.15 1.08, 1.23  Unemployed 8.3 5.07 2.20, 7.94 15.9 6.96 4.64, 9.29  Not in work force 0.8 – – 2.2 – – Marital status:  Married/cohabiting 74.4 1.26 1.13, 1.38 73.6 1.24 1.13, 1.34  Separated 3.8 1.46 0.21, 2.72 4.4 1.72 0.56, 2.89  Divorced 3.8 0.63 0.09, 1.18 5.5 0.97 0.38, 1.55  Widowed 0.8 – – 0.5 – –  Never married 17.3 0.70 0.44, 0.98 16.5 0.68 0.46, 0.91 Trauma exposure Table 2 shows the prevalence of each potentially traumatic event as personally experienced and the relative prevalence compared with the Australian population. Both sons and daughters reported experiencing more exposures to natural disasters, fire or explosion and transport accidents, whereas sons reported more exposures to toxic chemicals at work and daughters reported more sexual assault. More than one in 10 daughters reported actual rape, but sadly this was not different from the age-matched Australian contemporaneous female population. Table 2. Prevalence of traumatic events reported by sons and daughters, the relative prevalence (RP) and 95% confidence intervals (95% CI) compared with the age-sex matched Australian population, and the odds ratio (OR) and 95% confidence interval for the association of each traumatic event with PTSD in sons and daughters. (Empty cells indicate low reliability of parameters due to small sample size.) Sons(n = 133) Daughters(n = 182) Population comparison Sons PTSD Population comparison Daughters PSTD Prevalence (%) RP 95% CI OR 95% CI Prevalence (%) RP 95% CI OR 95%CI Natural disaster 30.1 3.10 2.29, 3.90 1.43 0.32, 6.28 29.1 3.92 3.03, 4.81 0.74 0.32, 1.69 Fire, explosion 20.3 3.60 2.39, 4.82 7.80 1.74,35.10 14.3 4.91 3.16, 6.65 0.68 0.22, 2.10 Transport accident 50.4 2.91 2.42, 3.40 3.15 0.61, 16.20 45.6 5.34 4.49, 6.18 2.69 1.27, 5.71 Exposure to toxic chemicals 15.0 2.15 1.28, 3.01 1.32 1.09, 1.60 6.0 2.18 0.93, 3.42 3.15 1.11, 8.95 Assault with weapon 20.3 1.14 0.76, 1.53 7.80 1.74, 35.10 14.8 1.53 1.00, 2.06 0.83 0.22, 3.04 Rape 0.8 – – 5.62 0.96, 33.08 11.5 1.15 0.69, 1.61 15.68 6.67, 36.8 Other sexual assault 6.8 1.34 0.50, 2.19 4.30 0.76, 24.43 24.7 1.35 1.01, 1.69 4.41 2.05, 9.48 Captivity 3.0 2.31 0.08, 4.53 (No cases with PTSD) 0.6 – – (No cases without PTSD) Life-threatening illness 9.8 1.47 0.71, 2.23 6.90 1.44, 33.18 9.3 1.28 0.70, 1.86 2.36 0.81, 8.65 Cause injury/death to another 5.3 2.92 0.82, 5.03 18.15 3.17, 103.80 2.2 3.64 0.11, 7.16 4.09 0.56, 30.02 Unexpected close death 22.6 0.67 0.46, 0.88 1.16 0.22, 6.04 31.3 0.88 0.69, 1.07 1.67 0.79, 3.53 Sons(n = 133) Daughters(n = 182) Population comparison Sons PTSD Population comparison Daughters PSTD Prevalence (%) RP 95% CI OR 95% CI Prevalence (%) RP 95% CI OR 95%CI Natural disaster 30.1 3.10 2.29, 3.90 1.43 0.32, 6.28 29.1 3.92 3.03, 4.81 0.74 0.32, 1.69 Fire, explosion 20.3 3.60 2.39, 4.82 7.80 1.74,35.10 14.3 4.91 3.16, 6.65 0.68 0.22, 2.10 Transport accident 50.4 2.91 2.42, 3.40 3.15 0.61, 16.20 45.6 5.34 4.49, 6.18 2.69 1.27, 5.71 Exposure to toxic chemicals 15.0 2.15 1.28, 3.01 1.32 1.09, 1.60 6.0 2.18 0.93, 3.42 3.15 1.11, 8.95 Assault with weapon 20.3 1.14 0.76, 1.53 7.80 1.74, 35.10 14.8 1.53 1.00, 2.06 0.83 0.22, 3.04 Rape 0.8 – – 5.62 0.96, 33.08 11.5 1.15 0.69, 1.61 15.68 6.67, 36.8 Other sexual assault 6.8 1.34 0.50, 2.19 4.30 0.76, 24.43 24.7 1.35 1.01, 1.69 4.41 2.05, 9.48 Captivity 3.0 2.31 0.08, 4.53 (No cases with PTSD) 0.6 – – (No cases without PTSD) Life-threatening illness 9.8 1.47 0.71, 2.23 6.90 1.44, 33.18 9.3 1.28 0.70, 1.86 2.36 0.81, 8.65 Cause injury/death to another 5.3 2.92 0.82, 5.03 18.15 3.17, 103.80 2.2 3.64 0.11, 7.16 4.09 0.56, 30.02 Unexpected close death 22.6 0.67 0.46, 0.88 1.16 0.22, 6.04 31.3 0.88 0.69, 1.07 1.67 0.79, 3.53 Table 2. Prevalence of traumatic events reported by sons and daughters, the relative prevalence (RP) and 95% confidence intervals (95% CI) compared with the age-sex matched Australian population, and the odds ratio (OR) and 95% confidence interval for the association of each traumatic event with PTSD in sons and daughters. (Empty cells indicate low reliability of parameters due to small sample size.) Sons(n = 133) Daughters(n = 182) Population comparison Sons PTSD Population comparison Daughters PSTD Prevalence (%) RP 95% CI OR 95% CI Prevalence (%) RP 95% CI OR 95%CI Natural disaster 30.1 3.10 2.29, 3.90 1.43 0.32, 6.28 29.1 3.92 3.03, 4.81 0.74 0.32, 1.69 Fire, explosion 20.3 3.60 2.39, 4.82 7.80 1.74,35.10 14.3 4.91 3.16, 6.65 0.68 0.22, 2.10 Transport accident 50.4 2.91 2.42, 3.40 3.15 0.61, 16.20 45.6 5.34 4.49, 6.18 2.69 1.27, 5.71 Exposure to toxic chemicals 15.0 2.15 1.28, 3.01 1.32 1.09, 1.60 6.0 2.18 0.93, 3.42 3.15 1.11, 8.95 Assault with weapon 20.3 1.14 0.76, 1.53 7.80 1.74, 35.10 14.8 1.53 1.00, 2.06 0.83 0.22, 3.04 Rape 0.8 – – 5.62 0.96, 33.08 11.5 1.15 0.69, 1.61 15.68 6.67, 36.8 Other sexual assault 6.8 1.34 0.50, 2.19 4.30 0.76, 24.43 24.7 1.35 1.01, 1.69 4.41 2.05, 9.48 Captivity 3.0 2.31 0.08, 4.53 (No cases with PTSD) 0.6 – – (No cases without PTSD) Life-threatening illness 9.8 1.47 0.71, 2.23 6.90 1.44, 33.18 9.3 1.28 0.70, 1.86 2.36 0.81, 8.65 Cause injury/death to another 5.3 2.92 0.82, 5.03 18.15 3.17, 103.80 2.2 3.64 0.11, 7.16 4.09 0.56, 30.02 Unexpected close death 22.6 0.67 0.46, 0.88 1.16 0.22, 6.04 31.3 0.88 0.69, 1.07 1.67 0.79, 3.53 Sons(n = 133) Daughters(n = 182) Population comparison Sons PTSD Population comparison Daughters PSTD Prevalence (%) RP 95% CI OR 95% CI Prevalence (%) RP 95% CI OR 95%CI Natural disaster 30.1 3.10 2.29, 3.90 1.43 0.32, 6.28 29.1 3.92 3.03, 4.81 0.74 0.32, 1.69 Fire, explosion 20.3 3.60 2.39, 4.82 7.80 1.74,35.10 14.3 4.91 3.16, 6.65 0.68 0.22, 2.10 Transport accident 50.4 2.91 2.42, 3.40 3.15 0.61, 16.20 45.6 5.34 4.49, 6.18 2.69 1.27, 5.71 Exposure to toxic chemicals 15.0 2.15 1.28, 3.01 1.32 1.09, 1.60 6.0 2.18 0.93, 3.42 3.15 1.11, 8.95 Assault with weapon 20.3 1.14 0.76, 1.53 7.80 1.74, 35.10 14.8 1.53 1.00, 2.06 0.83 0.22, 3.04 Rape 0.8 – – 5.62 0.96, 33.08 11.5 1.15 0.69, 1.61 15.68 6.67, 36.8 Other sexual assault 6.8 1.34 0.50, 2.19 4.30 0.76, 24.43 24.7 1.35 1.01, 1.69 4.41 2.05, 9.48 Captivity 3.0 2.31 0.08, 4.53 (No cases with PTSD) 0.6 – – (No cases without PTSD) Life-threatening illness 9.8 1.47 0.71, 2.23 6.90 1.44, 33.18 9.3 1.28 0.70, 1.86 2.36 0.81, 8.65 Cause injury/death to another 5.3 2.92 0.82, 5.03 18.15 3.17, 103.80 2.2 3.64 0.11, 7.16 4.09 0.56, 30.02 Unexpected close death 22.6 0.67 0.46, 0.88 1.16 0.22, 6.04 31.3 0.88 0.69, 1.07 1.67 0.79, 3.53 Sons and daughters reported a similar number of trauma exposures (M = 3.13, SD = 2.42; M = 2.72, SD = 2.10; respectively, for sons and daughters; t313 = 1.592, P = 0.112) but differed in the types of trauma experienced. Sons were more likely than daughters to experience a serious work accident [OR = 3.11, 95% CI (1.64, 5.85)], exposure to toxic chemicals [OR = 2.96, 95% CI (1.33, 6.53)], a physical assault [OR = 2.97, 95% CI (1.86, 4.76)] and assault with a weapon [OR = 2.56, 95% CI (1.32, 4.98)], whereas daughters were more likely to experience rape [OR = 8.31, 95% CI (1.91, 36.21)], sexual assault [OR = 3.92, 95% CI (1.89, 8.14)] and unwanted sexual experiences [OR = 3.32, 95% CI (1.67, 6.57)]. Table 2 also shows the odds ratios and 95% confidence intervals for the association of each potentially traumatic exposure with sons’ and daughters’ PTSD. Although sons had higher risk of exposure to natural disasters and transport accidents, these were not traumagenic; however exposure to fires/explosions and toxic chemicals were also associated with PTSD. Daughters also were at higher risk of natural disasters, fires and transport accidents than the population, but only accidents were traumagenic; rape and sexual assault bore higher risks for PTSD and sexual assaults were more common than in the background population. Further analysis revealed that 66.6% of daughters who reported rape reported that this was their ‘worst’ event, of whom 75% were diagnosed with PTSD, and 53.1% of those reporting sexual abuse reported this as their ‘worst’ event, of whom 19.2% were diagnosed with PTSD. Mental health Table 3 shows the prevalence of lifetime DSM-IV diagnoses among sons and daughters and the relative prevalence and 95% confidence intervals compared with the contemporaneous Australian population. For sons, there were higher than expected prevalences of alcohol dependence, drug abuse and dependence and major depression, whereas daughters experienced higher prevalence of alcohol abuse and dependence, drug abuse and dependence and major depressive disorders; daughters (but not sons) also experienced more PTSD and more generalized anxiety disorder than expected. Table 3. Prevalence of DSM-IV psychiatric diagnoses in sons and daughters of Australian Vietnam veterans and relative prevalence (RP) and 95% confidence intervals (95% CI) compared with the age-sex matched Australian population Sons Daughters Prevalence (%) RP 95% CI Prevalence (%) RP 95% CI Alcohol dependence 19.6 3.17 2.07, 4.26 12.1 3.50 2.13, 4.88 Alcohol abuse 21.8 0.80 0.54, 1.05 18.7 1.65 1.15, 2.15 Any drug dependence 12.0 2.41 1.30, 3.52 8.2 3.11 1.60, 4.62 Any drug abuse 18.8 2.27 1.47, 3.07 10.4 2.64 1.52, 3.76 Cannabis dependence 12.0 3.03 1.64, 4.42 3.3 2.44 0.52, 4.37 Cannabis abuse 13.5 1.81 1.03, 2.58 7.7 1.99 0.99, 2.98 Major depression 24.8 1.70 1.20, 2.21 42.3 1.92 1.59, 2.24 Dysthymic disorder 1.5 0.91 0.00, 2.36 1.7 0.76 0.00, 1.76 PTSD 6.0 0.89 0.29, 1.48 20.3 1.55 1.10, 2.00 Agoraphobia 1.5 0.97 0.00, 2.59 6.0 1.54 0.66, 2.43 Panic without agoraphobia 2.3 0.69 0.00, 1.45 5.0 1.45 0.53, 2.38 Panic with agoraphobia 0.8 1.12 0.00, 5.98 3.3 2.10 0.45, 3.76 Agoraphobia without panic 0.8 0.86 0.00, 2.15 0.6 0.23 0.00, 0.72 Social phobia 4.5 0.56 0.12, 0.99 16.5 1.37 0.92, 1.82 Generalized anxiety disorder 12.8 1.47 0.82, 2.13 16.5 1.96 1.32, 2.60 Bipolar I disorder 3.8 4.26 0.60, 7.92 3.3 3.00 0.64, 5.36 Suicidality  Suicide thoughts 17.3 1.19 0.75, 1.63 16.5 0.68 0.46, 0.92  Suicide plan 4.5 1.32 0.29, 2.35 15.4 2.77 1.83, 3.72  Suicide attempt 3.0 1.08 0.04, 2.12 8.2 1.90 0.98, 2.83 Sons Daughters Prevalence (%) RP 95% CI Prevalence (%) RP 95% CI Alcohol dependence 19.6 3.17 2.07, 4.26 12.1 3.50 2.13, 4.88 Alcohol abuse 21.8 0.80 0.54, 1.05 18.7 1.65 1.15, 2.15 Any drug dependence 12.0 2.41 1.30, 3.52 8.2 3.11 1.60, 4.62 Any drug abuse 18.8 2.27 1.47, 3.07 10.4 2.64 1.52, 3.76 Cannabis dependence 12.0 3.03 1.64, 4.42 3.3 2.44 0.52, 4.37 Cannabis abuse 13.5 1.81 1.03, 2.58 7.7 1.99 0.99, 2.98 Major depression 24.8 1.70 1.20, 2.21 42.3 1.92 1.59, 2.24 Dysthymic disorder 1.5 0.91 0.00, 2.36 1.7 0.76 0.00, 1.76 PTSD 6.0 0.89 0.29, 1.48 20.3 1.55 1.10, 2.00 Agoraphobia 1.5 0.97 0.00, 2.59 6.0 1.54 0.66, 2.43 Panic without agoraphobia 2.3 0.69 0.00, 1.45 5.0 1.45 0.53, 2.38 Panic with agoraphobia 0.8 1.12 0.00, 5.98 3.3 2.10 0.45, 3.76 Agoraphobia without panic 0.8 0.86 0.00, 2.15 0.6 0.23 0.00, 0.72 Social phobia 4.5 0.56 0.12, 0.99 16.5 1.37 0.92, 1.82 Generalized anxiety disorder 12.8 1.47 0.82, 2.13 16.5 1.96 1.32, 2.60 Bipolar I disorder 3.8 4.26 0.60, 7.92 3.3 3.00 0.64, 5.36 Suicidality  Suicide thoughts 17.3 1.19 0.75, 1.63 16.5 0.68 0.46, 0.92  Suicide plan 4.5 1.32 0.29, 2.35 15.4 2.77 1.83, 3.72  Suicide attempt 3.0 1.08 0.04, 2.12 8.2 1.90 0.98, 2.83 Table 3. Prevalence of DSM-IV psychiatric diagnoses in sons and daughters of Australian Vietnam veterans and relative prevalence (RP) and 95% confidence intervals (95% CI) compared with the age-sex matched Australian population Sons Daughters Prevalence (%) RP 95% CI Prevalence (%) RP 95% CI Alcohol dependence 19.6 3.17 2.07, 4.26 12.1 3.50 2.13, 4.88 Alcohol abuse 21.8 0.80 0.54, 1.05 18.7 1.65 1.15, 2.15 Any drug dependence 12.0 2.41 1.30, 3.52 8.2 3.11 1.60, 4.62 Any drug abuse 18.8 2.27 1.47, 3.07 10.4 2.64 1.52, 3.76 Cannabis dependence 12.0 3.03 1.64, 4.42 3.3 2.44 0.52, 4.37 Cannabis abuse 13.5 1.81 1.03, 2.58 7.7 1.99 0.99, 2.98 Major depression 24.8 1.70 1.20, 2.21 42.3 1.92 1.59, 2.24 Dysthymic disorder 1.5 0.91 0.00, 2.36 1.7 0.76 0.00, 1.76 PTSD 6.0 0.89 0.29, 1.48 20.3 1.55 1.10, 2.00 Agoraphobia 1.5 0.97 0.00, 2.59 6.0 1.54 0.66, 2.43 Panic without agoraphobia 2.3 0.69 0.00, 1.45 5.0 1.45 0.53, 2.38 Panic with agoraphobia 0.8 1.12 0.00, 5.98 3.3 2.10 0.45, 3.76 Agoraphobia without panic 0.8 0.86 0.00, 2.15 0.6 0.23 0.00, 0.72 Social phobia 4.5 0.56 0.12, 0.99 16.5 1.37 0.92, 1.82 Generalized anxiety disorder 12.8 1.47 0.82, 2.13 16.5 1.96 1.32, 2.60 Bipolar I disorder 3.8 4.26 0.60, 7.92 3.3 3.00 0.64, 5.36 Suicidality  Suicide thoughts 17.3 1.19 0.75, 1.63 16.5 0.68 0.46, 0.92  Suicide plan 4.5 1.32 0.29, 2.35 15.4 2.77 1.83, 3.72  Suicide attempt 3.0 1.08 0.04, 2.12 8.2 1.90 0.98, 2.83 Sons Daughters Prevalence (%) RP 95% CI Prevalence (%) RP 95% CI Alcohol dependence 19.6 3.17 2.07, 4.26 12.1 3.50 2.13, 4.88 Alcohol abuse 21.8 0.80 0.54, 1.05 18.7 1.65 1.15, 2.15 Any drug dependence 12.0 2.41 1.30, 3.52 8.2 3.11 1.60, 4.62 Any drug abuse 18.8 2.27 1.47, 3.07 10.4 2.64 1.52, 3.76 Cannabis dependence 12.0 3.03 1.64, 4.42 3.3 2.44 0.52, 4.37 Cannabis abuse 13.5 1.81 1.03, 2.58 7.7 1.99 0.99, 2.98 Major depression 24.8 1.70 1.20, 2.21 42.3 1.92 1.59, 2.24 Dysthymic disorder 1.5 0.91 0.00, 2.36 1.7 0.76 0.00, 1.76 PTSD 6.0 0.89 0.29, 1.48 20.3 1.55 1.10, 2.00 Agoraphobia 1.5 0.97 0.00, 2.59 6.0 1.54 0.66, 2.43 Panic without agoraphobia 2.3 0.69 0.00, 1.45 5.0 1.45 0.53, 2.38 Panic with agoraphobia 0.8 1.12 0.00, 5.98 3.3 2.10 0.45, 3.76 Agoraphobia without panic 0.8 0.86 0.00, 2.15 0.6 0.23 0.00, 0.72 Social phobia 4.5 0.56 0.12, 0.99 16.5 1.37 0.92, 1.82 Generalized anxiety disorder 12.8 1.47 0.82, 2.13 16.5 1.96 1.32, 2.60 Bipolar I disorder 3.8 4.26 0.60, 7.92 3.3 3.00 0.64, 5.36 Suicidality  Suicide thoughts 17.3 1.19 0.75, 1.63 16.5 0.68 0.46, 0.92  Suicide plan 4.5 1.32 0.29, 2.35 15.4 2.77 1.83, 3.72  Suicide attempt 3.0 1.08 0.04, 2.12 8.2 1.90 0.98, 2.83 There were only few differences between the sexes in the prevalence of DSM-IV diagnoses: sons were more likely to be cannabis dependent than daughters (OR = 4.02, 95% CI = 1.52, 10.52; P = 0.003), but social phobia was more prevalent among daughters (OR = 2.22, 95% CI = 1.15, 7.39; P = 0.033), as was depression (OR = 2.22, 95% CI = 1.36, 3.63; P = 0.002), particularly recurrent depression (OR = 4.41, 95% CI = 2.14, 9.09; P < .001). There were no differences in the prevalence of any disorder between sons and daughters conceived after the veteran’s return and those born before his deployment. Suicidality among sons was not different from population expectations; however, among daughters there was less suicidal ideation but more planning; for both sons and daughters there was no increase in attempts compared with population expectations. Daughters had higher levels of suicidal ideation than sons (OR = 3.53, 95% CI = 1.41, 8.84; P = 0.005) and higher prevalence of planning (OR = 4.62, 95% CI = 1.02, 21.02; P = 0.030) but no difference in the rate of attempts (OR = 3.73, 95% CI = 0.043, 32.30; P = 0.201). Children’s PTSD and mental health Table 4 shows the adjusted odds ratios and 95% confidence intervals for comorbidity with children’s PTSD, and the attributable risk31 (AR) associated with PTSD. Among sons, PTSD was associated with drug abuse and dependence, particularly cannabis dependence. For sons, the AR was very low only for alcohol and cannabis abuse; highest ARs occurred for drug and cannabis dependence. For daughters, their lower risk of alcohol abuse was counterbalanced by a higher risk of dependence, for which more than two-thirds can be attributed to PTSD. This suggests that daughters with PTSD avoid alcohol abuse and more readily descend into dependence. Among daughters, PTSD was associated with alcohol, drug and cannabis dependence, major depressive disorder, social phobia, generaliszd anxiety and bipolar I disorders. Cannabis and drug dependence seem also highly associated with PTSD, and PTSD was associated with more than three-quarters of the cases of depression, more than half the cases of anxiety and 70% of the cases of alcohol dependence, all of which were in excess of proportions in the general population. Table 4. Adjusted odds ratios (OR) and 95% confidence intervals (CI) for comorbidity of DSM-IV psychiatric diagnoses with PTSD in sons and daughters of Australian Vietnam veterans, and the attributable risk (AR) of comorbidity associated with PTSD Sons Daughters OR 95% CI AR(%) OR 95% CI AR(%) Alcohol dependence 1.89 0.38, 9.31 47.12 3.29 1.17, 9.30 69.60 Alcohol abuse 1.03 0.41, 2.61 3.19 1.02 0.41, 2.57 1.96 Any drug dependence 37.03 6.47, 211.80 97.30 4.60 1.37, 15.45 78.28 Any drug abuse 11.41 2.36, 55.17 91.24 1.97 0.69, 5.58 49.11 Cannabis dependence 33.61 5.96, 189.53 97.02 12.47 1.27, 122.39 91.98 Cannabis abuse 1.09 0.12, 9.90 8.26 1.64 0.48, 5.54 39.02 Major depression 1.38 0.29, 6.70 52.49 4.45 1.94, 10.23 77.55 Social phobia 3.35 0.34, 32.90 70.13 3.56 1.30, 9.74 71.89 Generalized anxiety disorder 5.02 0.94, 26.72 80.08 2.15 0.87, 5.34 53.55 Suicide thoughts 10.62 1.10, 103.09 90.59 3.68 1.51, 8.88 72.83 Suicide plan 7.71 1.00, 313.83 87.03 3.08 0.92, 10.33 67.53 Sons Daughters OR 95% CI AR(%) OR 95% CI AR(%) Alcohol dependence 1.89 0.38, 9.31 47.12 3.29 1.17, 9.30 69.60 Alcohol abuse 1.03 0.41, 2.61 3.19 1.02 0.41, 2.57 1.96 Any drug dependence 37.03 6.47, 211.80 97.30 4.60 1.37, 15.45 78.28 Any drug abuse 11.41 2.36, 55.17 91.24 1.97 0.69, 5.58 49.11 Cannabis dependence 33.61 5.96, 189.53 97.02 12.47 1.27, 122.39 91.98 Cannabis abuse 1.09 0.12, 9.90 8.26 1.64 0.48, 5.54 39.02 Major depression 1.38 0.29, 6.70 52.49 4.45 1.94, 10.23 77.55 Social phobia 3.35 0.34, 32.90 70.13 3.56 1.30, 9.74 71.89 Generalized anxiety disorder 5.02 0.94, 26.72 80.08 2.15 0.87, 5.34 53.55 Suicide thoughts 10.62 1.10, 103.09 90.59 3.68 1.51, 8.88 72.83 Suicide plan 7.71 1.00, 313.83 87.03 3.08 0.92, 10.33 67.53 Dysthymia, panic with agoraphobia, agoraphobia without panic, bipolar I and suicide attempt omitted due to small prevalence. Table 4. Adjusted odds ratios (OR) and 95% confidence intervals (CI) for comorbidity of DSM-IV psychiatric diagnoses with PTSD in sons and daughters of Australian Vietnam veterans, and the attributable risk (AR) of comorbidity associated with PTSD Sons Daughters OR 95% CI AR(%) OR 95% CI AR(%) Alcohol dependence 1.89 0.38, 9.31 47.12 3.29 1.17, 9.30 69.60 Alcohol abuse 1.03 0.41, 2.61 3.19 1.02 0.41, 2.57 1.96 Any drug dependence 37.03 6.47, 211.80 97.30 4.60 1.37, 15.45 78.28 Any drug abuse 11.41 2.36, 55.17 91.24 1.97 0.69, 5.58 49.11 Cannabis dependence 33.61 5.96, 189.53 97.02 12.47 1.27, 122.39 91.98 Cannabis abuse 1.09 0.12, 9.90 8.26 1.64 0.48, 5.54 39.02 Major depression 1.38 0.29, 6.70 52.49 4.45 1.94, 10.23 77.55 Social phobia 3.35 0.34, 32.90 70.13 3.56 1.30, 9.74 71.89 Generalized anxiety disorder 5.02 0.94, 26.72 80.08 2.15 0.87, 5.34 53.55 Suicide thoughts 10.62 1.10, 103.09 90.59 3.68 1.51, 8.88 72.83 Suicide plan 7.71 1.00, 313.83 87.03 3.08 0.92, 10.33 67.53 Sons Daughters OR 95% CI AR(%) OR 95% CI AR(%) Alcohol dependence 1.89 0.38, 9.31 47.12 3.29 1.17, 9.30 69.60 Alcohol abuse 1.03 0.41, 2.61 3.19 1.02 0.41, 2.57 1.96 Any drug dependence 37.03 6.47, 211.80 97.30 4.60 1.37, 15.45 78.28 Any drug abuse 11.41 2.36, 55.17 91.24 1.97 0.69, 5.58 49.11 Cannabis dependence 33.61 5.96, 189.53 97.02 12.47 1.27, 122.39 91.98 Cannabis abuse 1.09 0.12, 9.90 8.26 1.64 0.48, 5.54 39.02 Major depression 1.38 0.29, 6.70 52.49 4.45 1.94, 10.23 77.55 Social phobia 3.35 0.34, 32.90 70.13 3.56 1.30, 9.74 71.89 Generalized anxiety disorder 5.02 0.94, 26.72 80.08 2.15 0.87, 5.34 53.55 Suicide thoughts 10.62 1.10, 103.09 90.59 3.68 1.51, 8.88 72.83 Suicide plan 7.71 1.00, 313.83 87.03 3.08 0.92, 10.33 67.53 Dysthymia, panic with agoraphobia, agoraphobia without panic, bipolar I and suicide attempt omitted due to small prevalence. Suicidal ideation was associated with PTSD for both sons and daughters, with high ARs. Among sons there was no suicide attempt without PTSD, whereas among daughters there was no attempt with PTSD. These findings contrast with the PTSD-suicidality relationships displayed by their parents16 where ideation, planning and attempts were all higher than population expectations and all related to PTSD. Discussion This study has observed higher rates of some mental health problems among the sons and daughters of Australian Vietnam veterans than expected, based on similar age-sex matched information from the Australian population. It has also shown that veterans’ children were at higher risk of exposure to some potential traumas and have higher risk of PTSD than their peers in the general population. Although more highly educated, from more stable personal family environments and with better employment, veterans’ adult children appear to be at higher risk of alcohol and other substance use disorders and depressive disorders than expected. Daughters appear more prone to trauma exposures and consequent PTSD. The higher rates of sexual assault reported by daughters carried a higher rate of PTSD than seen in the Australian population and, although there was not more rape reported among daughters, the results reinforce the high level of traumagenicity associated with this type of experience. PTSD also carries significant comorbidity and increases the risk of disorders throughout the mental health realm, from depression and social phobia to alcohol, cannabis and drug dependence. Of concern are the findings in suicidality, both more prevalent in sons and daughters than population expectations and associated with PTSD. War service has ripple effects in families of combat veterans, where PTSD in veterans, who themselves have higher risk of alcohol misuse, depression and PTSD,3 increases the risk of PTSD in his children without necessarily increasing the risk of exposure to traumas,20 and alcohol disorders similarly increase the risk of alcohol disorders in their children.20 This increased risk in children is borne out here by the higher rates of alcohol disorder and PTSD. PTSD is accompanied by significant comorbidity, especially depression, anxiety and substance use disorders, consistent with the higher rates of these disorders in daughters and sons and the proportion that may be attributable to PTSD. Strengths and weaknesses Comparison of subpopulations with their ‘official’ parent populations is a means of making inferences about the health of a subgroup exposed to some factor in the absence of a dedicated control group that are not so exposed, but is not without uncertainties.27 Sons’ and daughters’ response rates were less than ideal (as was the ABS NSMHWB-07 that itself registered a response rate of only 60%). In particular, intelligence is itself a risk factor for PTSD, and the non-response analysis performed showed that the respondents had veteran fathers who were higher in intelligence; this suggests that the non-responders conceal veterans and offspring who may have higher rates of PTSD than observed here. Moreover, although the WHO CIDI has been reported to have high concordance with clinical diagnoses,34 it has been reported to underestimate PTSD rates in female US Vietnam-era veterans when compared with the CAPS.35 The NSMHWB 2007 PTSD module also included more potentially traumatic events than the CAPS, which may have increased the prevalence of PTSD in the 2007 ABS survey.31 However, for reasons of interview duration reduction, the ABS CIDI format did not include the three ‘worst’ events that were standard in previous versions of the CIDI and were structurally part of the CAPS interview. This is important, since eight of the 17 PTSD symptoms were referent to specific traumatic events, which also may have served to underestimate the prevalence of PTSD in the NSMHWB 2007. Although similar in many respects, the pattern of differences between the sexes may reflect a lack of generalizability to the greater population of sons, although many sex differences are cogent, such as the pattern of trauma exposures and related traumagenicity, the patterns of education particularly post-high school, income disparity and the higher risk of PTSD and depression among daughters. The question of generalizability to non-former military families is tempered by the demographic, trauma and mental health status of the sample of sons and daughters reported here. In addition, whereas the assessment instruments are highly structured, lack of funding and the wide geographical distribution of subjects rendered establishment of reliability via re-interview infeasible. Moreover, all interviewers were graduate-level researchers, which would not characterize ABS professional lay interviewers. Strengths of the study are its design as a nested study within the veterans’ cohort study, its use of standardized assessment measures and assessment by masters- or doctoral-level clinicians and researchers, likely not to be in the interviewing workforce of the ABS. This may have made the assessments more sensitive, as is intended with the administration of the CAPS, although the CIDI is highly structured and more resistant to interviewer effects. Whole-population estimates of the overall prevalence of PTSD are available, but comparisons with the present study may be misleading due to the different age structures in the published data. In the World Mental Health Surveys of trauma exposure36 and PTSD,37 the degree of traumatic exposure was not assessed in countries that have seen recent armed conflict, particularly in the Middle East and Africa; refugees were not included. These countries’ residents and refugees would be expected to display higher levels of trauma exposure and higher rates of PSTD. Even in developed countries with no recent non-terrorist related armed conflict, the degree of trauma exposure was reported to be of the order of 70%, yet the prevalence of PTSD was of the order of 4–6%. It may be predicted that an epidemic of trauma-related psychiatric problems is being generated by armed conflict, and this has the propensity to extend from the primary combatant into the next generation. Funding This work was supported by the Australian National Health and Medical Research Council (Grant Number 1011264). Conflict of interest: None declared. References 1 O'Toole BI , Marshall RP , Grayson DA et al. The Australian Vietnam Veterans Health Study. II. Self-reported health of veterans compared with the Australian population . Int J Epidemiol 1996 ; 25: 319 – 30 . 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International Journal of EpidemiologyOxford University Press

Published: Feb 7, 2018

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