Posttraumatic stress disorder (PTSD) is the 4th most common, non-substance related, psychiatric disorder in the United States. Patients with PTSD vs. those without have a significantly greater risk for type 2 diabetes (T2D) and cardiovascular disease (CVD) and mortality. Determining if PTSD improvement is associated with addresses NHLBI priorities and informs efforts to reduce health disparities related to psychiatric disorders. But even in patients who experience improvement, residual PTSD symptoms may contribute to adverse T2D/CVD outcomes. Thus, it is important to determine which PTSD symptoms or combination of symptoms are most strongly associated with adverse T2D/CVD outcomes in patients with comorbid PTSD and T2D or CVD. better T2D/CVD outcomes and lower mortality This proposal builds on our past 4-years of funded research We now move our focus away from incident T2D/CVD to outcomes in comorbid PTSD and T2D/CVD. There are no studies that have determined if patients with comorbid PTSD and T2D or CVD who do vs. do not have clinically meaningful PTSD improvement are at lower risk for adverse T2D/CVD outcomes and death. There are no studies which have determined if specific PTSD symptoms (e.g., hyperarousal) or combination of symptoms are associated with adverse T2D/CVD outcomes and mortality. Our design determines if PTSD improvement is followed by better T2D/CVD outcomes and whether this is mediated by disease management variables such as medication adherence. focused on PTSD treatment and improved health behaviors, and incident T2D and CVD. We do not study a specific type of PTSD therapy because we want to demonstrate whether PTSD is a modifiable risk factor for T2D/CVD adverse outcomes and mortality. As in the prior funding period, we use Department of Veterans Affairs’ medical record data. This is an ideal ‘laboratory’ to test our hypotheses. In a 10 year observation period (2012-2022) we will sample 15,193 patients with PTSD and comorbid T2D and 17,442 patients with PTSD and comorbid CVD. Our aims are 1) determine if separate PTSD phenotypes (derived from latent class analysis of PTSD symptoms), and symptom change, in patients with comorbid PTSD- T2D/CVD, are differentially associated with an increased risk for adverse T2D and CVD outcomes, including disease related and all-cause mortality, 2) determine whether risks for adverse T2D and CVD outcomes, all- cause and cause specific mortality are lower in patients with vs. without a clinically meaningful PTSD improvement ; 3) determine if measures of T2D/CVD management, such as good glycemic control, statin medication adherence and improved depression, mediate the association between clinically meaningful PTSD improvement and T2D/ CVD outcomes. and 4) conduct planned age, gender, and race sub-group comparisons. Decades of research on depression and T2D/CVD led to guidelines that acknowledge depression as a risk factor for poor CVD outcomes. Positive results and confirmatory studies may event...