"They're not mentally ill, their lives are just shit": Stakeholders' understanding of deaths of despair in a deindustrialised community in North East England.

Socioeconomic conditions, including socioeconomic status (SES) at the individual and neighborhood levels of organization, have been previously related to environmental exposures and their associated physical and mental health disorders and these relationships have, in turn, been attributed to disparities in material resources, psychosocial stress, and behavioral factors (, ). Military veterans differ from non-veterans with respect to health trajectories over the lifespan, given that SES, adverse childhood experiences, physical fitness, and psychosocial adjustment can affect acceptance into military service, and that those enlisted in the military are more likely than others to experience combat, injuries, violence, sexual trauma, chemicals, and infections, and these exposures potentially influencing resilience as well as a multitude of health outcomes (–). Military exposures, the experience of being separated from the military, and difficulties integrating into civilian life, can also manifest in terms of morbidity and mortality risks later in life (). Psychiatric disorders covering substance use and mental health disorders remain an issue of public health significance worldwide. A systematic review of studies using multiple international databases suggested that age-standardized disability-adjusted life-years attributable to psychiatric disorders were higher among women than men without substantial variation between 1990 and 2019 (). Women are currently the fastest growing segment among veterans and this trend has been attributed to expanded roles and advancement of women within the military (, ). Epidemiological evidence suggests that women veterans are more likely to report inferior general health, unhealthy behaviors, obesity, and higher risks for chronic conditions than women non-veterans (, , ). Traumatic experiences over the lifespan, within and outside of military service, have been shown to disproportionately affect women veterans, although evidence from population-based studies that compare substance use and mental health disorders among women veterans and non-veterans remain scarce (, –). Past studies of women veterans and non-veterans from the Women’s Health Initiative (WHI) have sought to characterize the health status of older women by veteran status (–, –, –). For instance, one study revealed a positive relationship between alcohol consumption and all-cause mortality (), and another study identified depressive symptoms to be positively related to pain (), but these relationships did not vary according to veteran status. However, none of these WHI studies have focused on diagnosed substance use and mental health disorders. Furthermore, many of the existing studies on psychiatric disorders among veterans relied on electronic health records data from the U.S. Department of Veterans Affairs (VA) and, therefore, may have failed to capture the entire picture because only a small percentage of veterans utilize the VA system for their healthcare (). Prospective cohort studies based on the WHI-Medicare linked database can improve our understanding in this respect, since they included women veterans who utilized VA and non-VA healthcare services. In this longitudinal study, we analyzed linked WHI-Medicare data on older women, who were ≥ 65 years at WHI enrollment and were followed for approximately 15 years, for the purpose of examining: [1] differences in prevalent and incident psychiatric disorders between women veterans and non-veterans; and [2] relationships of individual- and neighborhood-level SES indicators measured at WHI enrollment with prevalent and incident psychiatric disorders before and after stratification by veteran status. Likely due to military selection and healthcare access characteristics, veterans were previously found to experience better health outcomes than their non-veteran counterparts in the short term (). This phenomenon known as the “healthy soldier effect tends to wane and even be reversed over time, resulting in older veterans having worse health outcomes when compared to older non-veterans (). As such, we hypothesized that psychiatric disorders would be more frequently observed among older women veterans compared to other older women. We also hypothesized that SES indicators would be inversely related to frequencies of psychiatric disorders among older women and that these associations would vary by veteran status.