Research ArticleOriginal Research

Sex and Mental Health Disorder Differences Among Military Service Members With Patellofemoral Syndrome

Daniel I. Rhon, Tanja C. Roy, Robert C. Oh and Jodi L. Young
The Journal of the American Board of Family Medicine March 2021, 34 (2) 328-337; DOI: https://doi.org/10.3122/jabfm.2021.02.200323

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    Flow of cohort identification.

  • Figure 2.
    Figure 2.

    Concurrent presentation of mental health disorders before and after the initial patellofemoral knee pain diagnosis. PTSD, post-traumatic stress disorder.

  • Figure 3.
    Figure 3.

    Odds of mental health disorder presence based on sex. Odds are shown for females, with men as the reference standard (eg, women had 2.34 times the odds for a depression diagnosis before and 1.98 times the odds for a depression diagnosis after the initial patellofemoral pain diagnosis). PTSD, post-traumatic stress disorder.

Tables

  • Table 1.

    Baseline Variables between Groups Based on Mental Health Diagnosis Present in the Year before the Initial Knee Pain Visit

    TotalDepression n = 3179PTSD n = 1232Anxiety n = 2531Any MH Disorder n = 8490
    Male n = 58,203Female n = 23,629Male n = 1440 (45.3%)Female n = 1739 (54.7%)Male n = 1013 (82.2%)Female n = 219 (17.8%)Male n = 1317 (52.0%)Female n = 1214 (48.0%)Male n = 4765 (56.1%)Female - 3725 (43.9%)
    Mean age (SD)33.67 (8.63)32.39 (7.96)34.88 (8.29)32.88 (7.78)34.21 (7.47)32.29 (8.10)34.67 (7.85)32.62 (7.57)34.63 (8.38)32.49 (7.69)
    Age category n (%)
        17–30
        31–40
        41–50    		24,465 (42.0)
    18,931 (32.5)
    14,807 (25.4)    		10,814 (45.8)
    8539 (36.1)
    4276 (18.1)    		506 (35.1)
    529 (36.7)
    405 (28.1)    		756 (43.5)
    666 (38.3)
    317 (18.2)    		379 (37.4)
    404 (39.9)
    230 (22.7)    		102 (46.6)
    75 (34.2)
    42 (19.2)    		474 (36.0)
    499 (37.9)
    344 (26.1)    		522 (43.0)
    486 (40.0)
    206 (17.0)    		1753 (36.8)
    1696 (35.6)
    1316 (27.6)    		1663 (44.7)
    1424 (38.2)
    636 (17.1)
    Sponsor Service*
        Army
        Air Force
        Navy
        Marines
        Coast Guard
        Other/unknown    		28,260 (48.6)
    15,114 (26.0)
    6526 (11.2)
    4779 (8.2)
    1201 (2.1)
    2323 (4.0)    		10,106 (42.8)
    6894 (29.2)
    2882 (12.2)
    1708 (7.2)
    584 (2.5)
    1455 (6.2)    		864 (60.0)
    278 (19.3)
    144 (10.0)
    98 (6.8)
    12 (0.8)
    44 (3.1)    		836 (48.1)
    429 (24.7)
    195 (11.2)
    137 (7.9)
    33 (1.9)
    109 (6.3)    		786 (77.6)
    72 (7.1)
    39 (3.8)
    98 (9.7)
    0
    18 (1.8)    		127 (58.0)
    55 (25.1)
    13 (5.9)
    14 (6.4)
    4 (1.8)
    6 (2.7)    		808 (61.4)
    247 (18.8)
    120 (9.1)
    79 (6.0)
    23 (1.7)
    40 (3.0)    		560 (46.1)
    306 (25.2)
    135 (11.1)
    112 (9.2)
    29 (2.4)
    72 (5.9)    		2970 (62.3)
    878 (18.4)
    439 (9.2)
    293 (6.1)
    53 (1.1)
    132 (2.8)    		1762 (47.3)
    965 (25.9)
    395 (10.6)
    293 (7.9)
    84 (2.3)
    224 (6.0)
    Active duty (vs retired veteran)52,062 (89.4)22,832 (96.6)1239 (86.0)1683 (96.8)933 (92.1)210 (95.9)1180 (89.6)1188 (97.9)4203 (88.2)3624 (97.3)
    Socioeconomic status
        Junior Enlisted
        Senior Enlisted
        Junior Officer
        Senior Officer
        Other/unknown    		23,910 (41.3)
    23,623 (40.8)
    5286 (9.1)
    5058 (8.7)
    326 (0.6)    		9313 (39.4)
    8944 (37.9)
    2826 (12.0)
    2453 (10.4)
    93 (0.4)    		614 (42.6)
    653 (45.3)
    82 (5.7)
    90 (6.3)
    1 (0.1)    		726 (41.7)
    702 (40.4)
    167 (9.6)
    144 (8.3)
    0    		457 (45.1)
    462 (45.6)
    49 (4.8)
    45 (4.4)
    0    		107 (48.9)
    83 (37.9)
    16 (7.3)
    13 (5.9)
    0    		561 (42.6)
    607 (46.1)
    74 (5.6)
    75 (5.7)
    0    		510 (42.0)
    484 (39.9)
    120 (9.9)
    100 (8.2)
    0    		2041 (42.8)
    2153 (45.2)
    272 (5.7)
    294 (6.2)
    5 (0.1)    		1628 (43.7)
    1422 (38.2)
    363 (9.8)
    310 (8.3)
    0

    • PTSD, post-traumatic stress disorder; MH, mental health; SD, standard deviation.

    • ↵* For spouse or other dependent, this is the status of the individual in the family that is directly affiliated with the military.

  • Table 2.

    Relative Risk of Behavioral and Mental Health Diagnosis After Initial Knee Pain Visit With Men As the Reference Standard

    Risk Ratio (95% CI)Relative Risk Reduction (95% CI)Absolute Risk Reduction (95% CI)
    PTSD0.46 (0.42, 0.51)53.6% (49.1, 57.7)2.6% (2.3, 2.8)
    Depression2.16 (2.06, 2.26)−116.9% (−125.9, −106.3)−7.2% (−7.6, −6.7)
    Anxiety1.78 (1.70, 1.87)−78.0% (−86.7, 69.8)−4.9% (−5.4, −4.5)
    Any mental health disorder1.44 (1.40, 1.48)−44.0% (−47.9, −40.3)−8.5% (−9.2, −7.9)
    Substance use disorder0.51 (0.45, 0.57)49.5% (43.0, 55.2)1.3% (1.1, 1.5)

    • PTSD, post-traumatic stress disorder.

    • Values represent the risk for women in comparison to men. Negative numbers for relative or absolute risk indicate an increase in risk versus a reduction (ie, females had a negative relative risk reduction [−116.9%] for depression, indicating their risk increased).

  • Table 3.

    Health Care Use Outcomes Based on the Presence of Mental Health Disorders

    Total 2-Year Knee-Related Medical Costs Mean USD (95% CI)Total Knee-Related Care Visits Mean (95% CI)Two or More Episodes of Knee Pain (Recurrence) Odds Ratio (95% CI)At Least One Opioid Prescription Fill Odds Ratio (95% CI)
    No MH disorder diagnoses before1073 (1057, 1089)4.87 (4.82, 4.93)
    No MH diagnoses after1031 (1014, 1048)4.67 (4.62, 4.73)
    No MH diagnoses before or after1037 (1019, 1054)4.70 (4.64, 4.76)
    MH diagnosis present before diagnosis of patellofemoral pain
        Depression1076 (1007, 1149)5.05 (4.78, 5.33)0.98 (0.91, 1.06)1.27 (1.11, 1.44)*
        PTSD1175 (1073, 1286)5.27 (4.85, 5.71)1.30 (1.16, 1.46)*1.26 (1.02, 1.54)*
        Anxiety1065 (997, 1138)5.14 (4.84, 5.45)1.08 (0.995, 1.17)*1.35 (1.17, 1.56)*
        Any MH disorder1087 (1046, 1129)5.06 (4.90, 5.22)*1.11 (1.07, 1.17)*1.27 (1.16, 1.38)*
        Substance use disorder1158 (1081, 1241)*5.18 (4.89, 5.49)*1.10 (1.02, 1.19)*1.19 (1.03, 1.37)*
    MH diagnosis present after diagnosis of patellofemoral pain
        Depression1244 (1187, 1303)*5.73 (5.53, 5.93)*1.40 (1.33, 1.48)*1.43 (1.31, 1.56)*
        PTSD1487 (1400, 1579)*6.60 (6.28, 6.95)*1.89 (1.76, 2.02)*1.56 (1.38, 1.75)*
        Anxiety1263 (1204, 1324)*5.92 (5.70, 6.14)*1.33 (1.28, 1.41)*1.46 (1.34, 1.60)*
        Any MH disorder1231 (1197, 1266)*5.67 (5.55, 5.80)*1.41 (1.36, 1.45)*1.42 (1.33, 1.51)*
        Substance use disorder1120 (1027, 1221)5.28 (4.91, 5.67)1.27 (1.16, 1.39)*1.21 (1.02, 1.44)*
    New MH diagnosis present after diagnosis of patellofemoral pain
        Depression1275 (1206, 1348)*5.86 (5.63, 6.10)*1.43 (1.35, 1.52)*1.45 (1.30, 1.60)*
        PTSD1552 (1443, 1669)*6.87 (6.47, 7.29)*2.03 (1.87, 2.20)*1.61 (1.40, 1.84)*
        Anxiety1301 (1230, 1376)*6.03 (5.78, 6.29)*1.39 (1.31, 1.48)*1.49 (1.35, 1.65)*
        Any MH disorder1264 (1220, 1310)*5.80 (5.64, 5.97)*1.42 (1.37, 1.48)*1.37 (1.27, 1.47)*
        Substance use disorder1099 (994, 1215)5.23 (4.81, 5.68)*1.38 (1.24, 1.54)*1.26 (1.03, 1.54)*

    • MH, mental health; PTSD, post-traumatic stress disorder; USD, US dollars; OR, odds ratio; CI, confidence interval.

    • ↵* Value is significant at P < .05. Compared to NO mental health disorder either before or after initial patellofemoral pain diagnosis, the odds of having more than 1 knee pain episode were OR = 1.24 (95% CI 1.20, 1.28) and for filling at least 1 opioid prescription were OR = 1.37 (95% CI 1.29, 1.45).

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