Systematic Review of Women Veterans' Mental Health

Women's Health Issues 24-5 (2014) 485–502

www.whijournal.com

Original article

Systematic Review of Women Veterans’ Mental Health Jennifer J. Runnals, PhD a,b,*, Natara Garovoy, PhD, MPH c,d, Susan J. McCutcheon, RN, EdD d, Allison T. Robbins, BA a, Monica C. Mann-Wrobel, PhD a,b, Alyssa Elliott, BA a Veterans Integrated Service Network (VISN) 6 Mental Illness Research Education and Clinical Centers’ (MIRECC) Women Veterans Workgroup, Jennifer L. Strauss, PhD b,d a

VISN 6 Mental Illness Research, Education, Clinical Center (MIRECC), Durham, North Carolina Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina c Women’s Prevention, Outreach and Education Center, VA Palo Alto Healthcare System, Palo Alto, California d Department of Veterans Affairs, Mental Health Services, Washington, DC b

Article history: Received 27 February 2014; Received in revised form 13 June 2014; Accepted 30 June 2014

a b s t r a c t Background: Given recent, rapid growth in the field of women veterans’ mental health, the goal of this review was to update the status of women veterans’ mental health research and to identify current themes in this literature. The scope of this review included women veterans’ unique mental health needs, as well as gender differences in veterans’ mental health needs. Methods: Database searches were conducted for relevant articles published between January 2008 and July 2011. Searches were supplemented with bibliographic reviews and consultation with subject matter experts. Findings: The database search yielded 375 titles; 32 met inclusion/exclusion criteria. The women veterans’ mental health literature crosses over several domains, including prevalence, risk factors, health care utilization, treatment preferences, and access barriers. Studies were generally cross-sectional, descriptive, mixed-gender, and examined Department of Veterans Affairs (VA) health care users from all service eras. Results indicate higher rates of specific disorders (e.g., depression) and comorbidities, with differing risk factors and associated medical and functional impairment for female compared with male veterans. Although satisfaction with VA health care is generally high, unique barriers to care and indices of treatment satisfaction exist for women. Conclusions: There is a breadth of descriptive knowledge in many content areas of women veterans’ mental health; however, the research base examining interventional and longitudinal designs is less developed. Understudied content areas and targets for future research and development include certain psychiatric disorders (e.g., schizophrenia), the effects of deployment on woman veterans’ families, and strategies to address treatment access, attrition, and provision of gender-sensitive care. Published by Elsevier Inc.

The women veteran population is growing and is projected to increase from 8% to 15% by 2035 (Office of the Actuary, Department of Veterans Affairs (2011)). Since 2000, the There are no financial conflicts of interest to report. Funding for preparation of the manuscript was provided, in part, by the VISN 6 MIRECC at the DVAMC. The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. * Correspondence to: Jennifer J. Runnals, PhD, VISN 6 MIRECC, Durham Veterans Affairs Medical Center (DVAMC), 508 Fulton Street, Building 5, Durham, NC. Phone: (919) 286-0411 ext. 4609; fax: (919) 416-5912. E-mail address: [email protected] (J.J. Runnals). 1049-3867/$ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.whi.2014.06.012

Department of Veterans Affairs (VA) has witnessed a one-third increase (28% in fiscal 2000 to 38% in fiscal 2010) in the proportion of women accessing outpatient mental health services (Frayne et al., 2010; Frayne et al., 2012). Although recent studies have often focused on predominantly younger veterans of the conflicts in Iraq and Afghanistan, women aged 45 to 64 use outpatient mental health services more frequently, and the VA has witnessed more growth within this age group relative to younger women (Frayne et al., 2010; Frayne et al., 2012). The VA’s commitment to ensuring equitable access to high-quality health care for women veterans of all ages has

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fueled a burgeoning field of research (Yano et al., 2011). For example, in a review of women veterans’ health research published between 2004 and 2008, Bean-Mayberry and colleagues (2011) found that more research was published within that 5year period than during the 25 previous years. Given the growth of the women veteran population accessing mental health services and the similarly swift pace of advancement in women’s health research, the current review on women veterans’ mental health is merited and timely. The current project was designed to update and refocus prior reviews that have primarily concentrated on the physical health of women veterans, with aspects of mental health care incorporated as a secondary theme (Batuman et al., 2011; Beann, Yano, & Mayberry et al., 2011; Goldzweig, Balekian, Rolo Shekelle, 2006). The present review places a primary focus on women veterans’ mental health across ages and service eras, and updates prior reviews by identifying salient mental health themes and key findings, and synthesizing current findings with those of past reviews. The scope of the current review was guided by the key question: What is known about women veterans’ unique mental health needs and gender differences in veterans’ mental health needs, including the delivery, effectiveness, barriers, and access to mental health services?

from the current review, which summarizes research related to women veterans’ mental health. Readers are referred to several recent reports (Hyun, Kimerling, & Pavao, 2009; Maguen, Cohen, Ren, Bosch, Kimerling, & Seal, 2012; Street, Gradus, Giasson, Vogt, & Resick, 2013; Suris & Lind, 2008; Turchik et al., 2012; Turchik & Wilson, 2010) for summaries of MST-related research. For retained articles, the following information was abstracted and is summarized in Table 1: Sample characteristics, sample size, study design and objectives, and main findings. Data Synthesis Retained articles were grouped into five topical categories. Categories were finalized at the point of data synthesis to reflect the scope of identified studies. The categories serve to organize study findings into discrete, nonoverlapping content domains, and map onto the key question regarding women veterans’ unique mental health needs and gender differences in veterans’ mental health needs: 1) Screening and prevalence, 2) risk factors or vulnerabilities, 3) related medical and functional impairment, 4) utilization and barriers to care, and 5) satisfaction with VA health care. The identified themes and key findings for each of these topical category areas are described in the Results section.

Methods Search Strategy Using strategies developed by the Evidence-Based Synthesis Program Center, VA Greater Los Angeles Healthcare System, a literature search was conducted using terms and databases identified for the Bean-Mayberry and colleagues (2011) systematic review. Searches were undertaken in MEDLINE (via PubMed), PsycINFO, WorldCat, and Web of Science for literature published between January 2008 and July 2011 (see Appendix 1 for search details). The 2008 start date corresponds chronologically to the end date of the Bean-Mayberry and colleagues (2011) review. Terms included “women,” “woman,” “gender,” “military,” and “veterans.” Database searches were supplemented by a bibliography review of identified articles and consultation with subject matter experts. Methodology and reporting conventions for this project were derived from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (available: www.prisma-statement.org). Study Selection and Data Abstraction Article titles underwent screening for relevance. Articles of relevance were examined independently by a minimum of two authors (N.G., M.M.-W., J.R., A.E.) at the abstract and full-text level. Final selections were reviewed by the senior author, who also arbitrated any rating disagreements. Inclusion/exclusion criteria were 1) English-language empirical studies, peerreviewed journals, 2) gender comparison or a focus on women veterans, 3) mental health topics, and 4) not included in prior reviews. The current work was first conducted in support of a VA/Department of Defense initiative to examine mental healthrelated gender differences in veteran and military populations. Within that initiative, a review of research pertaining to women and men’s experience of sexual harassment and assault during military service (military sexual trauma [MST]) was conducted separately from the review of women’s mental health-related research. In keeping with the organization of the reviews conducted for that initiative, articles pertaining to MST are excluded

Results Yield The search yielded 375 articles (Figure 1). Of these articles, 288 were deemed not pertinent during title/abstract review. Eighty-seven underwent full-text review and 55 were removed (Figure 1 details reasons for removal). The remaining 32 articles underwent data abstraction and categorization into the five content areas (not mutually exclusive): Screening and prevalence (n ¼ 10), risk factors or vulnerabilities (n ¼ 7), medical and functional impairment (n ¼ 5), utilization and barriers (n ¼ 11), and satisfaction with VA health care (n ¼ 2; Table 1). Description of Evidence Studies were primarily observational. Two studies reported secondary analyses of an intervention trial (Schnurr et al., 2007) included in previous reviews. Twenty-five studies examined veterans accessing the VA health care system for services (“VA users”). Twenty-two examined mixed-gender cohorts and, with the exception of the Vogt studies (Vogt, Smith, et al., 2011; Vogt, Vaughn, et al., 2011), included predominately male samples. Eighteen studies examined records from national databases with sample sizes ranging from 12,605 to over 4 million. Thirteen studies recruited participants from between one and nine VA medical centers, with sample sizes ranging from 183 to 11,736. Eleven studies examined Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) era veterans; the remainder consisted of mixed (OEF/OIF and prior service era; n ¼ 3), prior era (pre-OEF/ OIF; n ¼ 3), or unidentified service era veterans (n ¼ 13). Two studies examined the organization of women veterans’ mental health care by seeking information from VA medical center administrators and/or clinicians. Major findings within content areas are reported, and overarching themes and trends are identified to characterize the state of empirical research on women veterans’ mental health.

Table 1 Summary of Reviewed Articles Author/ Content Area*

Sample Size/Cohort

Sample Characteristics

Banerjea 2009: 1

n ¼ 16,368 Prior service era cross cohort.

Burnett-Zeigler 2011: 5

Design/Objective

Main Findings

Females VHA users with diabetes in Observational/correlational FY 1999–2000. Cross-sectional, national database study; examining prevalence of mental illness and SUD among female veterans with diabetes.

VHA National Diabetes Epidemiologic Center Database Mental health/SUD diagnostic status using ICD-9 codes

54% had a mental illness, SUD, or both. The most prevalent diagnoses were: Depressive disorder (29%), anxiety disorder (13%), and tobacco use (10%). 6% diagnosed with alcohol or drug abuse. SUD (tobacco, alcohol and/or drug abuse) was more prevalent among those with SMI versus other mental illnesses (8% vs. 1%).

n ¼ 55,578 Cohort not specified

VHA users diagnosed with a psychiatric disorders and receiving VA outpatient treatment.

Stratified random sample without replacement of data from the National Survey of Healthcare Experiences of Patients: New primary care, established primary care, and specialty care from each VHA clinic.

96% of veterans with psychiatric disorders reported that their provider listened to them. Veterans with PTSD were more likely to feel their provider listened to them compared with those with schizophrenia. 91.9% of veterans felt as though they were involved in making decisions about their health care. Veterans who were most likely to feel that they were not involved in the decision making process were <49 years old, nonWhite, unmarried, had some college, income <$30.000, and had a serviceconnected disability. Those diagnosed with bipolar, PTSD, or substance abuse were less likely to feel involved or to report confidence/trust in their provider. Younger veterans show a decreased level of satisfaction and more negative perception of care.

Cohen 2009: 4

n ¼ 249,440 Female ¼ 31,610 Male ¼ 217,793 OEF/OIF cohort.

New VHA users accessing VA health Observational/correlational OEF/OIF National Roster including ICD-9care between 10/2001 and 3/2007. Compare utilization of non-mental health diagnoses, type of visit, and associated medical services across three groups of OEF/ diagnoses. OIF veterans: Without mental disorders, mental disorders other than PTSD, and PTSD.

Veterans with mental health disorders had 42%–146% (depending on service category) greater utilization of nonmental health VHA services than those without mental health disorders. Veterans with PTSD had the highest utilization rates. Female gender and lower rank were independently associated with greater utilization of health services.

Curran 2009: 4

n ¼ 8,064 Female ¼ 242 Male ¼ 7,822 Cohort not specified

VHA users receiving IOP substance use in FY 1999.

Observational/correlational Examine the perception of VA care among VHA patients with psychiatric diagnosis during outpatient medical visits.

Observational/correlational Explore patient and program-related variables associated with attrition from VA IOP substance use treatment.

31 IOP programs VHA administrative data: Count of visits in the identified IOP programs (5 visits in FY1999 vs. <5 visits).

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Study Setting/Primary Outcome Variables

27% of veterans terminated treatment early (i.e., <5 visits). Older age, female gender, and psychotic disorder diagnosis were associated with greater likelihood of premature termination. Higher rates of attrition were observed among IOP programs that offered more hours of treatment. 487

Female contemporaneous cohort (4/1/04–11/30/07) n ¼ 1,738 OEF/OIF ¼ 1258 PER ¼ 380 VIET ¼ 100

Female multi-era war zone veterans accessing care from the VHA specialized PTSD outpatient program and male OEF/OIF veterans. 2004–2007 and 1992– 1995.

Observational/correlational VHA’s Northeast Program Evaluation Differences in characteristics and mental Center Database, VHA outpatient PTSD health needs of women OEF/OIF vs. prior programs. eras, and female vs. male OEF/OIF veterans.

Among female war zone veterans: OEF/OIF veterans had less psychopathology and more social support than Vietnam era; and less psychopathology and less exposure to sexual/noncombat trauma than Persian Gulf era. Compared with OEF/OIF era males, females had fewer interpersonal and economic supports, greater exposure to different types of trauma, and different levels of pathology.

Female noncontemporaneous cohort (2/1/92–9/30/95) n ¼ 298 PER ¼ 227 VIET ¼ 71

Frayne 2008: 1, 4

n ¼ 4,429,414 Females ¼ 362,571 Males ¼ 4,066,843 Cohort not specified

VHA users FY 2002.

Observational/descriptive Determine whether gender differences in utilization and cost of VHA care differ after accounting for veteran status.

VHA National Patient Care Database, outpatient and inpatient. Cross-sectional analysis of variables including veteran’s status, service utilization, and costs.

Nonveterans (predominantly employees) accounted for 50.7% of women users, 3% of male users. In the full sample, females, compared with males, used fewer VHA outpatient and inpatient services at a fairly low cost. When the cohort was limited to veterans only, gender differences diminish considerately, and patterns of outpatient use reversed. Female spouses of fully disable veterans had utilization and costs similar to those of female veterans.

Frayne 2011: 3

n ¼ 90,558 Females ¼ 12,831 Males ¼ 77,727 OEF/OIF cohort

OEF/OIF VHA users with PTSD compared with veterans with no mental health conditions in FY 2006–2007.

Observational/correlational VHA National Patient Care Database Examine gender differences in the burden of linked to OEF/OIF Roster. medical illness among veterans with PTSD compared with those with no mental health conditions, and identify common comorbid conditions.

Median number of medical conditions among females was 7.0 vs. 4.5 for those with PTSD vs. those with no mental health conditions, and 5.0 vs. 4.0 for males. Among female OEF/OIF veterans with PTSD, the most common medical conditions were lumbosacral spine disorders, headache, and lower extremity joint disorders. Among male OEF/OIF veterans with PTSD, the most common medical disorders were lumbosacral spine disorders, lower extremity join disorders, and hearing problems. Both male and female OEF/OIF veterans with PTSD experience a greater burden of illness than veterans with no mental health diagnosis. (continued on next page)

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Male OEF/OIF cohort n ¼ 9,998

488

Fontana 2010: 1,2,3

Table 1 (continued) Sample Size/Cohort

Sample Characteristics

Design/Objective

Study Setting/Primary Outcome Variables

Main Findings

Freedy 2010: 1

n ¼ 865 Female ¼ 184 Male ¼ 681 Prior era: cohort not specified

Randomized, stratified sample of VHA users who attended primary care at 1 of 4 VHA medical centers in FY 1999.

Observational/correlational Examined gender differences in lifetime prevalence of traumatic events, PTSD, and depression.

VHA primary care from 4 facilities. Clinic interview (included validated screening measures), telephone interview (included validated diagnostic instruments), and medical record review.

Females reported higher lifetime rates of physical and sexual victimization, whereas males reported higher rates of war zone exposure. Among females, results of adjusted logistic regression models indicated that PTSD was associated with lifetime history of sexual victimization; lifetime depression was not associated with any variables in the model. Among males, results indicated that PTSD was associated with disability and war zone exposure; depression was associated with history of war zone exposure and interpersonal violence.

Friedman 2011: 4

n ¼ 193,434 new and returning patients in FY 2003 n ¼ 209,335 FY 2004 n ¼ 225,220 FY 2005 n ¼ 237,966 FY 2006 n ¼ 250,458 FY 2007 n ¼ 265,324 FY 2008 Cohort not specified

Females who accessed VHA outpatient services from FY 2003– 2009

Observational/correlational VHA National Patient Care Database, Describe demographic characteristics, outpatient utilization, and retention of new and returning female VHA patients over a 7-year period

In 2009, almost two thirds of new female patients were <45 years old and 43% had a service connection. In 2008, 88% of new female patients received primary care and 40% received mental health care. The number of female patients who had 3 mental health visits per year increased from 11% in 2003 to 20% in 2008.

Grubaugh 2008: 1

n ¼ 183 AfricanAmerican ¼ 84 Caucasian ¼ 99 WWII ¼ 4.4% Pre-Korea ¼ 3.2% Korea ¼ 9.2% Pre Vietnam ¼ 5.5% Vietnam ¼ 23.5% Post Vietnam ¼ 42.6% PGW ¼ 37.7%

Randomized, stratified sample of VHA users attending primary care in FY 1999.

Observational/correlational Compare rates of trauma, PTSD, other psychiatric disorders, functioning, and use of VHA services and disability benefits.

VHA primary care from 4 facilities. Clinic interview (included validated screening measures), telephone interview (included validated diagnostic instruments), and medical record review.

Caucasian females reported higher rates of child sexual abuse; African-American women reported higher rates of physical assault. No significant racial differences in rates of psychiatric diagnoses, functional status, and use of VHA services and disability benefits among female veterans.

Haskell 2011: 4

n ¼ 163,812 Female ¼ 19,520 Male ¼ 144,292 OEF/OIF cohort

Enrolled in VHA care 1 visit within Observational/correlational 1 year of last deployment and Describe gender differences in medical and before 01/2008. mental health conditions, and utilization rates among recently separated OEF/OIF veterans.

VHA National Patient Care Database, Decision Support System, and Corporate Data Warehouse.

Compared with males, females were younger, more frequently African American, and less likely to be married. Compared with males, females had more primary care and mental health visits, and higher use of non-VHA, community-based care. In adjusted analyses, females were more likely to be diagnosed with musculoskeletal and skin disorders, depression, and adjustment disorders; males were more likely to have ear disorders and PTSD. .3% of females sought gynecologic examinations, 10% contraceptive counseling, and 7% accessed services related to menstrual disorders.

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Author/ Content Area*

489

Veterans accessing any outpatient care, including mental health care, in FY 2007 and 1 clinic visit 1– 2 years prior.

Ilgen 2010: 2

n ¼ 3,291,891 Female ¼ 29,081 Male ¼ 2,968,810 Cohort not specified

Iverson 2011: 1

MacGregor 2011: 4

Data from VA Office of Quality and Performance External Peer Review Program Random sample of VA outpatients with AUDIT-C scores.

Alcohol misuse for Veterans 55 having served in Iraq or Afghanistan was 22% for men and 5% for women; OEF/OIF men were 3 times likelier to screen positive for alcohol misuse compared with OEF/OIF women. Compared with men without deployment, OEF/OIF male veterans, especially <30, had higher risk of alcohol misuse. No difference in alcohol misuse risk was noted for women with and without deployment to OEF/OIF; however, this analysis was underpowered to find significant differences.

Veterans accessing care in FY 1999, Observational/correlational and still living in FY 2000. Examine associations between psychiatric diagnoses and risk of suicide.

VHA National Patient Care Database and the CDC and Prevention’s National Death Index.

All psychiatric diagnoses were associated with increased risk of suicide. Women with substance use disorders and men with bipolar disorder were at a higher risk for suicide than individuals with other psychiatric diagnoses.

N ¼ 12,605 Female ¼ 654 Male ¼ 11,951 OEF/OIF cohort

Veterans evaluated by VHA and Observational/correlational judged to have deployment-related Examine gender differences in the TBI between 04/2007 and 08/2009. presence of psychiatric conditions and neurobehavioral symptom severity among OEF/OIF VHA patients with deployment-related TBI.

VHA National Patient Care, TBI screening database.

PTSD was the most common psychiatric condition for both females (59.6%) and males (67.8%) with deployment-related TBI. Females were no less likely than males to have a diagnosis of PTSD after adjusting for blast exposure during deployment. Relative to males, females were 2 more likely to have depression diagnosis, 1.3 more likely to have an anxiety disorder, and 1.5 more likely to have PTSD with comorbid depression. Females reported significantly more severe neurobehavioral symptoms across a range of symptom domains.

n ¼ 36 Cohort not applicable

VHA administrators and clinicians experienced with women’s mental health services in 2007.

Out of 91 facilities, 30 participating in VHA Survey of Women Veterans Health Programs and Practices. Semistructured telephone interviews related to women’s mental health services.

Facilities in the VHA system have developed a variety of programs designed to deliver women’s mental health services, including specialized providers, women-only mental health groups, and women’s mental health clinics. There is a lack of consensus about the needs of female veterans and the consequences of changing programs designed for them. Some respondents were concerned about stigma resulting from separate mental health service for women.

Observational/correlational Examine prevalence of alcohol misuse (AUDIT-C score 5), and brief alcohol intervention (BI), and compare between OEF/OIF and non-OEF/OIF veterans.

Observational/descriptive Qualitative exploration of the development and structure of mental health services for female veterans.

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n ¼ 12,092 Female ¼ 2009 Male ¼ 10,083 OEF/OIF and pre-OEF/ OIF 55 years old.

490

Hawkins 2010: 1

Table 1 (continued) Sample Characteristics

Design/Objective

Study Setting/Primary Outcome Variables

Main Findings

Maguen 2010: 1,2

n ¼ 329,049 Female ¼ 40,701 Male ¼ 288,348 OEF/OIF cohort

VHA users accessing services between 04/01/2002 and 03/31/ 2008.

Observational/correlational Examined gender differences in veteran characteristics and common mental health diagnosis associations.

VHA National Patient Care Database linked with OEF/OIF Roster.

Relative to males, female OEF/OIF veterans were, on average, younger, and more likely to be African American and diagnosed with depression. Male veterans were more likely than females to be diagnosed with PTSD and alcohol use disorders. Older age was associated with high rates of depression and PTSD diagnosis for females but not males.

Mattocks 2010: 2

n ¼ 43,078 OEF/OIF cohort

Female VHA users discharged from AD between 10/01/2001 and 04/20/ 2008 and of childbearing age (50) with 1VHA visit.

Observational/correlational Examine the prevalence of mental health problems among female OEF/OIF veterans who received pregnancy-related care in VHA system.

VHA National Patient Care Database linked to OEF/OIF Roster.

7% received 1 episode of pregnancyrelated care. 32% with pregnancy (vs. 21% without pregnancy) received >1 mental health diagnosis. Those with pregnancy were twice as likely to be diagnosed with depression, anxiety, PTSD, bipolar disorder, or schizophrenia. Because females do not receive pregnancy care at VHA facilities, little is known about their ongoing concomitant prenatal and mental health care.

Mengeling 2011: 5

n ¼ 1,002 OEF/OIF PGW Post-Vietnam

Female veterans enrolled at one of two Midwestern VHA facilities between 07/2000 and 08/2008.

Observational/correlational Evaluate female veterans’ preferences and perceptions related to sole VHA care use or dual (both VHA and non-VHA) care.

Two Midwestern VHA Medical Centers. Telephone interview designed to measure physical and mental health functioning, PTSD, depression, and sexual abuse.

Sole and dual VA care users were more likely to have served in a combat zone, have a diagnosis of PTSD and poorer physical health compared with non-VHA patients. Non-VHA users were more likely to be married and have private health insurance. Sole VHA users were more likely to want to choose from a male or female health care provider. Sole users endorsed the most positive perceptions of VHA care, followed by dual users and non-VHA users, respectively.

Oishi 2011: 4

n ¼ 195 facilities Cohort not applicable

VHA administrators and clinicians experienced with women’s mental health services in 2007.

Observational/correlational Describe variations in the implementation of gender-sensitive mental health care arrangements (within or outside of mental health clinics), and factors predictive of women’s specialty mental health arrangements.

Senior Women’s Health Clinician module of the VHA Survey of Women Veterans Health Programs and Practices. Completed by senior clinicians identified by chief of staff at each facility; workload and caseload data were obtained from the VA’s centralized data repository.

Local implementation of gender-sensitive mental health care in VHA settings is highly variable. 53% of facilities had some form of gendersensitive mental health care arrangements. 34% reported having designated women’s mental health providers in general outpatient mental health clinics. 48% had therapy groups for women in their mental health clinics. VHAs with women’s primary care clinics also delivered mental health services (24%), and 12% of VHAs reported having a separate women’s mental health clinic, most of which (88%) offered sexual trauma group counseling. Assignment to same-gender mental health providers is not routine.

491

Sample Size/Cohort

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Author/ Content Area*

Female VHA users diagnosed with diabetes, heart disease, or hypertension in FY 2001.

Observational/correlational Examine association between organizational features of integrated physical and mental health care in women’s health clinics and diagnosis of depression among female veterans with or at risk for cardiovascular conditions.

VHA National Patient Care Database and Medicare fee-for-service claims. VHA Survey of Primary Care Practices, facility level, 1999. VHA Survey of Women Veterans Health Problems and Practices, 2001.

Overall, 27% of female VHA users were diagnosed with depression in FY2001. Across facilities, rates of diagnosed depression ranged from 13% to 41%. Female veterans who were served in separate women’s health clinics with integrated physical and mental health care were more likely to be diagnosed with depression, compared with those seen at sites that did not have available mental health care in women’s primary care clinics.

n ¼ 8,147 Cohort not specified

Female VHA users diagnosed with incident depression episodes and diabetes or coronary artery disease or hypertension FY 2002–2003.

Observational/correlational VHA medical records and Medicare Analyze variations in the treatment rates of fee-for-service claims data. depression among women veterans with diabetes, coronary artery disease, or hypertension by demographic, socioeconomic, and health status characteristics.

26.5% of African-American women compared with 17.1% of White women had no prescriptions for antidepressants or psychotherapy visits within 180 days. Psychotherapy rather than antidepressant use was more likely among AfricanAmerican women than White women (32%:18.9%). Women >65 were more likely to have no depression treatment compared with women <50. Women with anxiety disorders and PTSD were less likely to receive no depression treatment compared with women with psychotic disorders.

Sayers 2009: 3

n ¼ 199 Female ¼ 21 Male ¼ 178 OEF/OIF cohort

VHA users referred for behavioral health evaluation at the Philadelphia VA Medical Center between April 2006 and August 2007.

Observational/correlational Examine associations between psychiatric symptoms and family reintegration problems.

Philadelphia VAMC referred by primary care clinicians. Validated self-report and interview-based measures of psychiatric symptoms, family readjustment problems, and domestic abuse.

Three quarters of the married/cohabitating veterans reported some type of family problem in the past week. Among those with separated partners, 53.7% reported conflicts involving “shouting, pushing, or shoving,” 27.6% reported that their partner was “afraid of them”. Depression and PTSD were associated with higher rates of family problems.

Schnurr 2009: 3

n ¼ 242

Female veterans and AD with PTSD recruited from 12 VHA/military medical centers and randomly assigned to 10 sessions of prolonged exposure or presentcentered therapy.

RCT Examine the relationship between PTSD symptoms and sexual outcomes; treatment effects on sexual outcomes; the relationship between change in PTSD and change in sexual outcomes.

9 VA Medical Centers; 2 VA Readjustment Centers; 1 Department of Defense hospital. Validated measures employed at baseline, post-treatment, and 3- and 6-month follow-up.

At baseline, reexperiencing, numbing, and hyperarousal symptom clusters were related to one or both sexual outcomes. There were no between-treatment differences on sexual outcomes. Across treatment groups, loss of PTSD diagnosis was associated with improvements in sexual concerns. (continued on next page)

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Sambamoorthi, BeanMayberry 2010: 4

492

Sambamoorthi, n ¼ 27,972 Shen 2010: 4 Cohort not specified

Table 1 (continued) Sample Characteristics

Design/Objective

Study Setting/Primary Outcome Variables

Main Findings

Schnurr 2011: 3

n ¼ 253

Female veterans and AD with PTSD recruited from 12 VHA/military medical centers and randomly assigned to 10 sessions of prolonged exposure or presentcentered therapy.

RCT See above Examined 3 components of work-related quality of life (employment status, clinicianrated occupational impairment, and selfrated occupational satisfaction); analyses performed with and without adjusting for self-reported depression symptoms.

Greater PTSD severity was related to poor occupational outcomes, although the associations differed across the 3 components of work-related quality of life. All PTSD symptom clusters were independently associations with occupational impairment. All PTSD symptom clusters, except avoidance, were significantly associated with lower occupational satisfaction; none were independently associated with occupational satisfaction. No single symptom cluster was most strongly associated with occupational outcomes. Depression symptoms were related to all components, independent of PTSD symptoms.

Seal 2011: 4

n ¼ 526 Female ¼ 63 Male ¼ 463 OEF/OIF cohort

VHA users initiating primary care at the San Francisco VHA Medical Center between 04/01/2005 and 04/31/2009.

Observational/correlational Retrospective comparison of a VA IC clinic, offering a 3-part primary care, mental health and social services visit, improved psychosocial services utilization compared with UC.

San Francisco VAMC IC and UC primary care data.

Compared with UC, veterans presenting to the IC primary care clinic were significantly more likely to have had a within-30-day mental health evaluation (92%vs. 59% and social services evaluation (77% vs. 56%). Female gender, younger age, and positive mental health screens were independently associated with greater likelihood of mental health and social service evaluations, if seen in the IC versus UC clinic. Results indicate that an integrated primary care visit increased the likelihood of an initial mental health and social services evaluation, but did not improve retention in specialty mental health services.

Shen 2010: 1

n ¼ 13,430 Cohort not specified

Female VHA users diagnosed with chronic cardiovascular disease and depression FY 2003–2004.

Observational/correlational Retrospective, cross-sectional analysis of rates of major and minor depression in women VHA users with cardiovascular disease.

VHA administrative data merged with Medicare claims FY 2002; VHA Survey of Primary Care Practices 1999.

60% were diagnosed with minor depression and 40% with major depression. Compared with those with major depression, those with minor depression were, on average, older and less likely to be diagnosed with a comorbid psychiatric or substance use disorders.

Strauss 2011: 2

n ¼ 200

Female VHA users receiving outpatient mental health care between 2001 and 2003.

Observational/correlational Examine associations between self-reported history of trading sex for payment, childhood sexual trauma, and MST.

Durham VAMC Women’s Health Clinic and outpatient mental health. Clinical interview that included validated measures and medical record review.

19.7% reported a lifetime history of ever trading sex. Those who traded sex had relatively higher rates of MST; and MST uniquely predicted likelihood of ever having traded sex in adjusted analyses that controlled for demographic variables, childhood sexual trauma, and current substance abuse.

Vogt, Vaughn 2011: 2

n ¼ 592 Females ¼ 340 Males ¼ 252 OEF/OIF cohort

Derived from national, stratified random sample those returned from deployment between 10/01/ 2007 and 07/31/2008.

Observational/correlational Evaluate gender differences in combatrelated stressors and consequences on postdeployment mental health.

Defense Manpower Data Center; Active Duty, National Guard and Reserve Forces. Mailed survey of validated measures of combat-related stressors, PTSD, depression, substance abuse, and mental health functioning.

Females reported slightly less exposure to combat-related stressors than males. There were no gender differences in perceived threat in the war zone. Results suggest that males and females veterans of OEF/OIF are equally resilient to combat stress.

493

Sample Size/Cohort

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Author/ Content Area*

Wallace 2009: 4

n ¼ 28,083 alcohol Female veterans and civilians treatment episodes for admitted into alcohol use disorder veterans treatment from 1992–2003. n ¼ 1.5 million alcohol treatment episodes for civilians

Washington 2011: 4

n ¼ 3,611 OEF/OIF: 4.8% Pre-Vietnam: 14.2% Vietnam era: 81%

National, random, stratified sample Observational/correlational of women veterans. Explore factors associated with delayed or unmet health care needs among women veterans.

National Survey of Women Veterans telephone survey.

18.9% of women had delayed or unmet health care need in last month; being younger was associated with this. More women with delayed/unmet health care needs were minorities, low income, disabled, poorer health status, without a regular medical provider, lacked insurance, and had a mental health diagnosis. Reasons for delayed/unmet need included lack of affordable care, inability to take off from work (women 50) and lack of transportation (women 65). Lack of knowledge of VA care, perception that VA providers do not render gendersensitive care, and history of MST were associated with delayed/unmet health care needs.

Westermeyer 2009: 1

n ¼ 362 Female ¼ 28 Male ¼ 334 Cohort not specified

American Indian veterans in the catchment areas of the Albuquerque and Minneapolis VA Medical Centers, found using the 1990 Census.

Counties with 10 American Indian veterans. Validated self-report instruments and computer-based diagnostic and health care algorithms.

Females had lower scores on alcohol and drug abuse screenings, fewer self-reported PTSD symptoms, and were less likely to use VHA mental health services, but more willing to seek mental health treatment, if needed. Men had higher rates of drug abuse and more combat exposure.

Postdeployment 12 months; derived from national, stratified random sample.

Observational/correlational See above Identify the mechanisms through which risk factors affect posttraumatic stress symptoms in OEF/OIF veterans, and compare these with findings reported in Vietnam veterans.

Most of the risk factor pathways previously found in Vietnam veterans were consistent for male and female OEF/OIF veterans, indicating these pathways might generalize across various veteran groups. Female and male EF/OIF veterans experienced more similar risk pathways than male and female Vietnam Veterans, possibly owing to changes in women’s roles in the military over time.

Observational/correlational U.S. Department of Health Treatment Explore changes in annual alcohol Episode Data Set. treatment rates among female veterans and civilians.

Policy changes associated with discouraging underage drinking among service members were associated with fewer alcohol treatment episodes for the younger female veteran groups who served during and after these changes, as compared with older females who were not affected by the policies. The observed reduction in alcohol treatment episodes among female veterans does not seem to reflect an overall societal trend, because the number of treatment episodes in the civilian sample only marginally decreased or increased in some age categories during this timeframe.

Observational/correlational Compare prevalence of substance use disorder diagnoses, severity, comorbidity, and course.

Abbreviations: AD, active duty; AUDIT-C, Alcohol Use Disorders Identification Test; BI, brief alcohol intervention; FY, fiscal year; IC, integrated care; ICD-9, International Classification of Diseases, 9th edition; IOP, intensive outpatient; MST, military sexual trauma; OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom; PGW, Persian Gulf War; PER, Persian Gulf; PTSD, posttraumatic stress disorder; RCT, randomized, controlled trial; SMI, severe mental illness; SUD, substance use disorder; UC, usual care; VA, Veterans Administration; VHA, Veterans Health Administration; VAMC, VA Medical Center; VIET, Viet Nam; WWII, World War II. * Content Areas: 1 ¼ Screening and Prevalence; 2 ¼ Risk Factors or Vulnerabilities; 3 ¼ Medical and Functional Impairment; 4 ¼ Utilization and Barriers; 5 ¼ Satisfaction with VA Care.

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n ¼ 579 Female ¼ 333 Male ¼ 246 OEF/OIF cohort

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Vogt, Smith 2011: 2

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Literature Searches (n=369)

495

Identified by Subject Matter Experts (n=6)

375 Articles Identified 288 Rejected After Abstract/Title Review

87 Articles Screened 55 Rejected After Full-Text Review: 47 Inclusion criteria not met 27 Sample criteria not met 6 Content criteria not met 14 Study design not appropriate 8 Overlap with prior evidence reviews*

32 Articles Assessed ** Screening and Prevalence of Mental Health Conditions (n=10) Risk Factors or Vulnerabilities Associated with Mental Health Conditions (n=7) Medical and Functional Impairment Associated with Mental Health Conditions (n=5) Mental Healthcare Utilization and Barriers to Care (n=11) Satisfaction with VA Care (n=2) *Batuman, F., Bean-Mayberry, B., Goldzweig, C.L., Huang, C., Miake-Lye, I.M., Washington, D.L., Yano, E.M., Zephyrin, L.C., Shekelle, P.G. Health Effects of Military Service on Women Veterans. VAESP Project # 05-226; 2011. Bean-Mayberry, B., Yano, E. M., Washington, D. L., Goldzweig, C., Batuman, F., Huang, C., Miake-Lye, I., Shekelle, P. G. (2011). Systematic review of women veterans’ health: Update on successes and gaps. Women's Health Issues, 21(4S), S84-S97. doi:10.1016/j.whi.2011.04.022 **Categories are not mutually exclusive: articles may be categorized under multiple headings.

Figure 1. Literature flow.

Screening and Prevalence of Mental Health Conditions Ten studies reviewed screening and prevalence, mostly among VA users. One half consisted of OEF/OIF-era veterans and half included national samples. Two themes consistent with prior work (Bean-Mayberry et al., 2011) emerged: 1) Women veterans exhibit similar rates of posttraumatic stress disorder

(PTSD) and higher rates of depression and non-PTSD anxiety disorders compared with male veterans (Freedy et al., 2010; Maguen, Ren, Bosch, Marmar, & Seal, 2010), and 2) higher rates of comorbidity are observed among women veterans. For example, relative to males, women veterans experience higher rates of comorbidity of PTSD and depression (Iverson et al., 2011). In addtion, co-morbidity of depression and

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medical conditions (cardiovascular conditions and diabetes Banerjea, Pogach, Smelson, & Sambamoorthi, 2009; [Shen, Findley, Banerjea, & Sambamoorthi, 2010]) was high. In gender comparisons of OEF/OIF-era veterans, women evidenced higher rates of non-PTSD anxiety disorder diagnoses than men (Fontana, Rosenheck, & Desai, 2010; Iverson et al., 2011; Maguen et al., 2010). For example, among 329,049 VA users, 12% of women and 10% of men received a non-PTSD anxiety disorder diagnosis, and 23% of women versus 17% of men received a depression diagnosis (Maguen et al., 2010). Among 183 pre OEF/ OIF-era veterans accessing VA primary care, anxiety disorder, PTSD, and depression diagnoses occurred slightly more in African-American than Caucasian women; however, these differences were not statistically significant (Grubaugh, Stagle, Long, Frueh, & Magruder, 2008). Consistent with prior work (Batuman et al., 2011), the frequency of eating disorder prevalence was quite low, and slightly higher in OEF/OIF female (0.6%) than male VA users (0.1% [Maguen et al., 2010]). OEF/OIF women accessing VA health care services were less likely to be diagnosed with an alcohol use disorder than OEF/OIF men accessing VA health care (3% vs. 8% [Maguen et al., 2010]). In samples including VA users and nonusers, women veterans were also less likely to be diagnosed with a SUD (Iverson et al., 2011; Westermeyer et al., 2009) and, among VA users, the rate of alcohol misuse was lower among female compared with male OEF/OIF-era veterans (5% vs. 22% [Hawkins, Lapham, Kivlahan, & Bradley, 2010]). Overall, among veterans who received VA health services in 2002, women were more likely to carry a mental health diagnosis (38% vs. 30% [Frayne et al., 2008]) than men. Risk Factors or Vulnerabilities Associated with Mental Health Conditions Seven observational studies examined risk factors and vulnerabilities, primarily among VA users. Four studies included OEF/OIF-era veterans, two included prior service-era veterans, and one a blend of service eras. Most studies were mixed gender with predominately male veterans, with the exceptions of Mattocks and colleagues’ (2010) study of 43,078 OEF/OIF-era women veterans, Strauss and colleagues’ (2011) study of 200 blended-era women veterans, as well as the Vogt and associates’ studies (Vogt, Smith, et al., 2011; Vogt, Vaughn, et al., 2011) that used a stratified sample from the Defense Manpower Data Center that included 50% women veterans. Overall, data suggest that, compared with their male counterparts, women veterans accessing VA care may face unique challenges with regard to mental health, and social and financial support (Fontana et al., 2010; Strauss et al., 2011). For example, female OEF/OIF veterans with PTSD were more likely to be unmarried than their male counterparts (Maguen et al., 2012) and pregnant veterans were more likely to be younger, unmarried, have service-connected disabilities, and have higher rates of mental health diagnoses (32% vs. 21% [Mattocks et al., 2010]) relative to nonpregnant veterans. For both genders, postdeployment relationship disruption was associated with postdeployment trauma symptoms (mediated by perceived threat during deployment), and women veterans with greater relationship concerns reported less postdeployment social support (Vogt, Smith, et al., 2011) than women veterans with fewer relationship concerns. Across genders, being enlisted in the Army and undergoing multiple deployments increased risk for PTSD (Maguen et al., 2010). Among women veterans, older age was uniquely associated with greater

PTSD prevalence and chronicity, which was hypothesized by the investigators to reflect higher rates of cumulative trauma exposure or more deployment-related disruption of social and family networks, relative to younger women (Fontana et al., 2010; Maguen et al., 2010). Across genders, predeployment factors seem to have greater influence on postdeployment mental health among OEF/OIF-era as compared with prior-era veterans, with women reporting more predeployment life stressors and sexual harassment during deployment compared with men (Vogt, Vaughn et al., 2011). Previous work reported lower suicide risk among female compared with male veterans (Batuman et al., 2011). Recent work has more specifically indicated that women veterans with SUDs and men with bipolar disorder have increased risk for suicide (Ilgen et al., 2010). Medical and Functional Impairment Associated with Mental Health Conditions Five articles addressed medical and functional impairment associated with mental health conditions. These studies were primarily observational and, when mixed gender, conducted in predominately male samples and among VA users. Two articles reported secondary analyses from a large, multisite PTSD treatment trial in women veterans and service members (Schnurr et al., 2009; Schnurr & Lunney, 2011). Two studies derived data from VA national databases (Fontana et al., 2010; Frayne et al., 2011); the remaining studies derived data from one VA medical center. Overall, among veterans with PTSD, health, occupational, and interpersonal impairments are greater among women than men. In terms of health impairment, a national, cross-sectional study of 90,558 OEF/OIF VA users found that women with PTSD had almost twice the number of medical conditions as women without PTSD (particularly lumbosacral spine disorders, headaches, and lower extremity disorders), and more medical illnesses than men with PTSD (Frayne et al., 2011). In addition, disrupted sexual functioning was observed in a sample of 242 women who participated in a PTSD psychotherapy trial (prolonged exposure and presentcentered therapy); therapy was minimally effective in reducing women veterans’ sexual concerns (Schnurr et al., 2009). Schnurr and Lunney (2011) also reported moderate to severe PTSDrelated occupational impairment in these women, with greater PTSD symptomatology associated with more work impairment and dissatisfaction. Depression and PTSD symptoms have also been linked to disruption of family functioning (Sayers, Farrow, Ross, & Oslin, 2009), with three fourths of partnered veterans reporting a family conflict in the past week (broadly defined, and including reports of shouting, shoving, or pushing). However, given the small proportion of women in this study, women veterans’ experiences could not be reliably evaluated. OEF/OIF-era women veterans in PTSD treatment reported more trauma exposure and fewer interpersonal and economic coping resources than men, despite lower rates of psychopathology relative to prior-era women veterans (Fontana et al., 2010). Mental Health Care Utilization and Barriers to Care Twelve descriptive studies discussed utilization and barriers; 11 included VA users or medical center administrators/providers and 1 examined data from a national, stratified sample. Three focused on OEF/OIF-era veterans; the remainder were not

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service-era specific. Several studies included only women, and mixed-gender studies were able to obtain representative samples of veterans (approximately 12% women) owing to use of national patient datasets (Cohen et al., 2009; Frayne et al., 2008; Friedman et al., 2011; Haskell et al., 2011; Sambamoorthi, BeanMayberry, Findley, Yano, & Banerjea, 2010; Wallace, Sheehan, & Young-Xu, 2009). Key findings are that women veterans of OEF/OIF tend to be younger and their health care utilization patterns showed a higher rate of growth across fiscal years 2003 through 2009 relative to their male counterparts. Compared with their male counterparts, OEF/OIF-era women veterans were younger (<45), less likely to be married, and more likely to be African American (Haskell et al., 2011). Among newly enrolled, younger women (not era specific), a pattern of increased utilization has been observed for VA primary care (84% in 2003 vs. 88% in 2009 [Cohen et al., 2009; Friedman et al., 2011]) and mental health services (24% in 2003 vs. 40% in 2009 [Friedman et al., 2011]). Almost one half of 193,434 women who accessed VA outpatient services (fiscal 2003–2009) had a service-connected disability (Friedman et al., 2011). Several studies examined barriers to accessing VA health care. Overarching findings are that women’s economic (e.g., lack of transportation), organizational (e.g., hours of care), and patient factors (e.g., poor health) are challenges to VA health care access and utilization. In a national stratified sample of 3,608 women veterans, demographic, socioeconomic, and clinical barriers to accessing VA health care included younger age, racial minority, lack of insurance, low income, fair to poor health status, disability, mental health diagnosis, and history of MST (Washington, Bean-Mayberry, Riopelle, & Yano, 2011). Logistical barriers included the inability to take time off from work (cited among those 50) and lack of transportation (cited among those 65). Observed knowledge gaps included lack of awareness of eligibility for care and the availability of readjustment counseling services, and the perception among some that VA health care providers may not be sensitive to the concerns of women (Washington et al., 2011). A survey of 195 administrators and providers at VA medical centers serving 300 or more women found that gender-sensitive outpatient mental health care for women (operationalized by the authors to include women-only treatment environments and/or designated women’s mental health providers in either womenonly or mixed-gender clinics) was available in one half of VA medical centers surveyed and was generally organized in one of three ways: 1) Designated women’s providers in mixed-gender general mental health clinics (34%), 2) mental health providers in women’s health clinics (24%), or 3) women’s mental health clinics (12%; [Oishi et al., 2011]). Academically affiliated VA medical centers with larger caseloads of women were more likely to offer these services. Because the Oishi and colleagues’ (2011) study was not evaluative, their findings cannot be used to draw comparative conclusions among health care delivery structures. A qualitative study that explored models for delivering women’s mental health services indicated that, although the 26 VA medical centers evaluated lacked formally “designated” women’s mental health providers, some providers became informally known for primarily treating women, and hence functioned as “de facto” women’s providers (MacGregor, Hamilton, Oishi, & Yano, 2011). Separate work examining local variations in the structure of care delivery among 526 OEF/OIF veterans at one VA medical

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center indicated that, as compared with nonintegrated care, integrated physical and mental health care (IC; the provision of colocated primary care with mental health and social services) was associated with greater likelihood of within 30-day mental health evaluation (92% IC vs. 59% non-IC) and social service evaluation (77% IC vs. 56% non-IC), particularly for women (Seal et al., 2011), and IC may also result in better depression detection for women (Sambamoorthi, Bean-Maryberry, et al., 2010). However, IC was not associated with reduced attrition from mental health treatment (Seal et al., 2011). Finally, among VA users with SUDs, attrition was greater for those who were older, female, or diagnosed with a psychotic disorder (Curran, Stecker, & Booth, 2009). Among 8,147 VA users with depression and cardiovascular disease and/or diabetes, women age 65 or older engaged in less depression treatment than younger women, and African-American women were more likely to engage in psychotherapy than Caucasian women (32% vs. 18.9% [Sambamoorthi, Shen, Findley, Frayne, & Banerjea, 2010]). Satisfaction with VA Health Care Two studies addressed satisfaction with VA health care, but not mental health care specifically, in mixed or nonspecified service-era cohorts (Burnett-Zeigler, Zivin, Ilgen, & Bohnert, 2011; Mengeling, Sadler, Torner, & Booth, 2011). Overall, findings were consistent with prior work (Bean-Mayberry et al., 2011) and indicate that VA users generally have positive perceptions of VA health care. For example, among 55,578 male and female VA users with psychiatric disorders, nearly all (91%) rated their last episode of care positively. Most indicated their provider listened to them (96%) and inspired confidence and trust (95%), and that they were as involved in decisions about their care as they wanted to be (92%). Relatively lower ratings of VA health care were predicted by service-connected disability status, younger age, ethnic minority status, and diagnosis of bipolar disorder, SUD, or PTSD (Burnett-Zeigler et al., 2011). Among 1,002 female, Midwestern veterans age 52 or younger, sole VA and dual users (mixed VA and non-VA health care) compared with non-VA users endorsed positive perceptions of VA health care, particularly related to privacy and safety concerns. For example, 94% of sole VA users indicated that VA medical centers provide adequate privacy and safety during examinations compared with 65% of non-VA users; 79% of VA users felt safe from sexual harassment at VA medical centers versus 66% of non-VA users; and 64% of VA users endorsed the perception that VA medical centers serve men and women equally well, versus 47% of non-VA users. Most (96%) endorsed a preference for health care services “specific to women’s needs” (e.g., gynecology) and many endorsed preference for choice of provider gender (64%); sole VA users and dual users were more likely than non-VA users to express provider gender preference, as were urban versus rural women (Mengeling et al., 2011). Summary of Key Findings Screening and Prevalence Higher rates of non-PTSD anxiety disorders, depression, and medical comorbidities were observed among women, whereas higher rates of substance use were observed among men.

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Risk Factors or Vulnerabilities Women OEF/OIF veterans have experienced less postdeployment social and financial support than men. Across genders, relationship disruption is associated with greater risk for postdeployment trauma symptoms. For women, older age is associated with greater PTSD prevalence and chronicity. Medical and Functional Impairment Higher rates of health and functional impairments were observed among women compared with men, and limited data (predominantly in males) link depression and PTSD to postdeployment family reintegration difficulties among veterans. Utilization and Barriers to Health Care Compared with men, new female VA users are younger and show increasing use of VA health services. Veteran-level barriers to accessing VA health care include economic limitations and clinical factors associated with psychiatric disorders. Organizational barriers for women veterans include availability of gendersensitive mental health services, which are present most often in academically affiliated VA medical centers with larger caseloads of women. Satisfaction with VA Care Veterans with psychiatric disorders, in particular older veterans, have generally positive views of VA health care. Women accessing VA health care have more positive perceptions of the VA than women who use mixed (VA and non-VA) or no VA health care. Discussion The impact of recent conflicts and the evolution of women’s role in our military have fueled a period of unparalleled growth in the field of women veterans’ research. This rapid growth stimulated the current project, which was undertaken to update prior women’s health research reviews (Batuman et al., 2011; Bean-Mayberry et al., 2011; Goldzweig et al., 2006). The current review uniquely focuses on women veterans’ mental health and is inclusive of all service eras. Results are consistent with prior reviews in several areas, such as the identification of gender differences in prevalence and risk factors for certain mental health conditions, higher rates of comorbid conditions in women relative to men, and the continued scarcity of interventional designs and studies that include veterans who are non-VA health care users. The current review newly identified a paucity of postdeployment/post-military service longitudinal studies. Such longitudinal studies would allow for examination of the proximal and distal effects of intervention on symptoms, functional impairments, and relapse and remission rates. The studies that we reviewed also provide important information about new female enrollees to VA health care, in particular highlighting that relative to men, OEF/OIF-era women are younger and use more VA health care services (Maguen et al., 2010) and that women have more mental health co-morbidities and significant medical comorbidities (Iverson et al., 2011; Maguen et al., 2010; Sambamoorthi, Bean-Mayberry, et al., 2010; Sambamoorthi, Shen, et al., 2010). Our knowledge of the prevalence and impact of mental health conditions across women veterans’ lifespan is increasing (Mattocks et al., 2010), as is our understanding of these women’s unique barriers to care (Mengeling et al., 2011) and the effects of health care organization on detection and treatment of mental health conditions

(Seal et al., 2011). Implicit within this literature is that the majority of women (and men) veterans are not experiencing significant mental health difficulties. For example, 94% of women did not screen positive for alcohol misuse (Hawkins et al., 2010) and 73% of women VA users were not diagnosed with depression in fiscal 2001. Indeed, many veterans report positive effects of their service, such as improved self-confidence and ability to cooperate with others, and personal growth (for a review see Rewards to Military Service in Institute of Medicine [2013]). In addition to the need for longitudinal study designs, this review also identified knowledge gaps in several content areas. Relatively understudied topics include the prevalence and treatment of depression, non-PTSD anxiety disorders, serious mental illnesses such as schizophrenia, SUDs in women, and risks and protective factors associated with the development of mental health problems. Such studies would inform future research and clinical programming, including, when indicated, development of gender-tailored prevention and treatment interventions. Likewise, the current research literature on the impact of postdeployment reintegration on veterans and their families is limited to predominantly male veteran cohorts. Additional studies are needed to identify potential gender differences in family reintegration, including effects on family and marital functioning, children’s well-being and parenting, and potential preventative and treatment targets to mitigate reintegration problems. For example, depression and PTSD have been linked to disrupted family functioning among male veterans (Sayers et al., 2009). The impact of these conditions on women veteransdwho commonly serve as family caregiverdand their families has not yet been examined. As undertaken by some (Schnurr et al., 2009; Schnurr & Lunney, 2011), additional studies that look beyond mental health conditions to identify and address functioning problems more generally (e.g., social, interpersonal, and occupational impairments) would broaden knowledge about the effects of military service on women veterans’ lives. In addition, across genders, more data are needed on factors contributing to psychotherapy treatment retention and satisfaction with mental health care. Finally, although significant progress has been made in describing the organization and availability of services for women veterans, understanding best practices for the provision of gender-sensitive care remains an area for growth. Germane to these observations, initiatives supporting further growth of women veterans’ mental health research, and linkages between clinical priorities and research (Hayes, 2013) are underway. For example, the VA has a strong commitment to funding research on women veterans. This commitment includes pioneering strategies to create the national research infrastructure needed to expand VA’s capacity to conduct research in women veterans, such as the VA Health Services Research and Development-funded Practice-Based Research Network and Women’s Health Consortium (Frayne et al., 2013; Yano et al., 2011). These and similar programs have already resulted in significant evidence-based knowledge growth on gender differences and women veterans’ mental health. Finally, limitations of the current review merit mention. This review was restricted to evidence published in peer-reviewed journals between January 2008 and July 2011. Although efforts were made to capture all relevant articles, it is possible that articles were overlooked. Efforts were undertaken to mitigate data omission by supplementing database searches with bibliography reviews and consultations with subject matter experts. Further, 24 of the 32 studies examined women veterans accessing VA

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health care. Given that prior work has shown higher illness burden among veterans accessing VA care compared with veterans not accessing VA care (e.g., Nelson, Starkebaum, & Reiber, 2007; Rogers et al., 2004), the current work may not be representative of all women who have served in the military and consequently may limit the generalizability of these results. Additionally, use of large VA administrative datasets, although an asset in terms of inclusion of larger samples of women veterans, also comes with drawbacks: Data are collected for clinical not research purposes and thus may not be ideally “fitted” to the research question(s), the data cannot account for clinic variability, and diagnostic codes may vary in reliability (e.g., depending on how the diagnosis was derived). These and similar concerns are noted within the limitations of relevant studies included in this review. Implications for Practice and/or Policy The current findings underscore the breadth of knowledge available in many content areas relevant to women veterans’ mental health. However, understudied content areas exist. Notably, the research base examining interventional and longitudinal designs, and including non-VA health care users, is much less developed than the current, largely descriptive and observational, body of research examining women VA health care users. Future research may advance the field by developing and testing strategies to reduce gender disparities and identifying best practices for provision of gender-sensitive care, to guide clinicians and policymakers in methods to more fully address the unique mental health care needs of women veterans. Acknowledgments Preparation of this manuscript was supported in part by VISN 6 MIRECC. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government. The authors wish to thank the following for their thoughtful input: Dr. Jenny Hyun, Dr. Kathleen Iverson, Dr. Jan Kemp, Ms. Linda Lipson, Ms. Isomi Miake-Lye, Dr. Paul Shekelle, Dr. Dawne Vogt, the Evidence-Based Synthesis Program Center, West Los Angeles VA Medical Center, and the Integrated Mental Health Strategy, Strategic Action #28 d Gender DifferencesdTask Group. The VISN 6 MIRECC Women Veterans Workgroup consists of the following members: Jean C. Beckham, Mira Brancu, Michelle Kelley, Suzanne E. Kerns, Monica MannWrobel, Allison T. Robbins, Jennifer J. Runnals, Kristy Straits€ster, Jennifer L. Strauss, and Elizabeth Van Voorhees. Tro References Banerjea, R., Pogach, L. M., Smelson, D., & Sambamoorthi, U. (2009). Mental illness and substance use disorders among women veterans with diabetes. Women’s Health Issues, 19(6), 446–456. Batuman, F., Bean-Mayberry, B., Goldzweig, C., Huang, C., Washington, D. L., Yano, E. M., et al. (2011). Health effects of military service on women veterans. (No. VA-ESP Project # 05–226). Washington, DC: Department of Veterans Affairs Health Services Research & Development Service. Bean-Mayberry, B., Yano, E. M., Washington, D. L., Goldzweig, C., Batuman, F., Huang, C., et al. (2011). Systematic review of women veterans’ health: Update on successes and gaps. Women’s Health Issues, 21(4S), S84–S97. Burnett-Zeigler, I., Zivin, K., Ilgen, M. A., & Bohnert, A. S. B. (2011). Perceptions of quality of health care among veterans with psychiatric disorders. Psychiatric Services, 62(9), 1054–1059. Cohen, B. E., Gima, K., Berthenthal, D., Kim, S., Marmar, C. R., & Seal, K. H. (2009). Mental health diagnoses and utilization of VA non-mental health medical

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Author Descriptions Jennifer J. Runnals, PhD, works for the Mid-Atlantic Mental Illness Research Educational and Clinical Center, Durham, North Carolina, and the Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina. Her research interests include trauma, chronic pain, and women’s mental health.

Natara Garovoy, PhD, MPH, works in the Women’s Counseling Center, VA Palo Alto Health Care System, Palo Alto, California, and the Mental Health Services, Department of Veteran Affairs, Washington, DC. Her research interests include stress and trauma, gender and women’s mental health, and health promotion.

Susan J. McCutcheon, EdD, works for the Office of Mental Health Services in the Department of Veteran Affairs, Washington, DC. Her research interests include women’s mental health, military sexual trauma, impact of deployment, and reintegration of families.

Allison T. Robbins, BA, works in the Mid-Atlantic Mental Illness Research Educational and Clinical Center, Durham, North Carolina. Her research interests include trauma, complex posttraumatic stress disorder, chronic health concerns, and resiliency in families.

Monica C. Mann-Wrobel, PhD, works at the Mid-Atlantic Mental Illness Research Educational and Clinical Center, Durham, North Carolina, and the Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina. Her research interests include complex posttraumatic stress disorder, serious mental illness, third-wave behavioral interventions, couples, and families.

Alyssa Elliott, BA, works for the Mid-Atlantic Mental Illness Research Educational and Clinical Center, Durham, North Carolina. Her research interests include trauma, interpersonal violence, and resiliency in military families.

Jennifer L. Strauss, PhD, works for the Office of Mental Health Services, Department of Veteran Affairs, Washington, DC, and the Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina. Her research interests include women’s mental health, trauma, clinical trials, and integrative medicine.

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Appendix 1: Women Veterans Health Care – 2011 Update Search Methodologies

Forward Searches on the Following Articles (Date From 2008– 2011):

Database Searched and Time Period Covered:

Med Care. 2003 Aug; 41(8):950–61. Gender Differences in service connection for PTSD. Murdoch M, Hodges J, Hunt C, Cowper D, Kressin N, O’Brien N. Results: 8. J Gen Intern Med. 2003 Mar; 18(3):175–81. Patient satisfaction in women’s clinics versus traditional primary care clinics in the Veterans Administration. Bean-Mayberry BA, Chang CC, McNeil MA, Whittle J, Hayes PM, Scholle SH. Results: 6. J Gen Intern Med. 2006 Mar; 21 Suppl 3:S11–8. To use or not to use. What influences why women veterans choose VA health care. Washington DL, Yano EM, Simon B, Sun S. Results: 13. Author(s): Washington, DL (Washington, DL); Yano, EM (Yano, EM); Horner, RD (Horner, RD) Source: Journal of General Internal Medicine Volume: 21 Supplement: 3 Pages: S3-S4 http://dx.doi.org/10.1111/j.15251497.2006.00367.x Published: MAR 2006. Results: 1. J Gen Intern Med. 2006 Mar; 21 Suppl 3:S82–92. The state of women veterans’ health research. Results of a systematic literature review.  n C, Yano EM, Shekelle PG. Goldzweig CL, Balekian TM, Rolo The health and health care of women veterans - Perspectives, new insights, and future research directions. Results: 23.

PubMed: 2008-7/25/2011. Search Strategy: women* OR female*[tiab] OR gender. AND veteran* AND systematic[sb] OR meta-analy* OR metaanaly* OR meta analys* OR women’s health services OR quality OR utili* OR patient satisfaction OR satisf*[tiab]) Number of Results: 309. “Related Article” Searches on the Following Articles (Date From 2008–2011): Med Care. 2003 Aug; 41(8):950-61. Gender Differences in service connection for PTSD. Murdoch M, Hodges J, Hunt C, Cowper D, Kressin N, O’Brien N. J Gen Intern Med. 2003 Mar; 18(3):175–81. Patient satisfaction in women’s clinics versus traditional primary care clinics in the Veterans Administration. Bean-Mayberry BA, Chang CC, McNeil MA, Whittle J, Hayes PM, Scholle SH. J Gen Intern Med. 2006 Mar; 21 Suppl 3:S11–8. To use or not to use. What influences why women veterans choose VA health care. Washington DL, Yano EM, Simon B, Sun S. Author(s): Washington, DL (Washington, DL); Yano, EM (Yano, EM); Horner, RD (Horner, RD) Source: Journal of General Internal Medicine Volume: 21 Supplement: 3 Pages: S3-S4 http://dx.doi.org/10.1111/j.15251497.2006.00367.x Published: MAR 2006. J Gen Intern Med. 2006 Mar; 21 Suppl 3:S82–92. The state of women veterans’ health research. Results of a systematic literature review.  n C, Yano EM, Shekelle PG. Goldzweig CL, Balekian TM, Rolo The health and health care of women veterans - Perspectives, new insights, and future research directions. Number of Results after Removing Duplicates from Search #1: 185.

Database Searched and Time Period Covered: PsycINFO: 2008-7/26/2011. women* OR female* OR gender. AND veteran* AND “systematic review” OR “systematic reviews” OR meta-analy* OR metaanaly* OR meta analys* OR “health services” OR quality OR utili* OR satisf* Search modes - Phrase Searching (Boolean) Number of results: 213. Database Searched and Time Period Covered:

Database Searched and Time Period Covered: Web of Science - Databases ¼ SSCI, A&HCI, CPCI-SSH: 2008-7/ 26/2011. Search Strategy: Topic ¼ (women* OR gender OR female*) AND Topic¼(veteran*) AND Topic ¼ (systematic[review* OR meta-analy* OR metaanaly* OR meta analys* OR “health services” OR quality OR utili* OR satisf*) Databases ¼ SSCI, A&HCI, CPCI-SSH. Number of results: 179.

Social Sciences Abstracts: 2008-7/26/2011. women* OR female* OR gender. AND veteran* AND “systematic review” OR “systematic reviews” OR meta-analy* OR metaanaly* OR meta analys* OR “health services” OR quality OR utili* OR satisf* Search modes - Phrase Searching (Boolean) Number of results: 4. Database searched and time period covered: WorldCat: 2008-7/26/2011. kw: women* OR kw: female* OR kw: gender. AND

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kw: veteran* AND kw: systematic w review OR kw: systematic w reviews OR kw: meta-analy* OR kw: metaanaly* OR (kw: meta and kw: analys*) OR kw: health w services OR kw: quality OR kw: utili* OR kw: satisf*

NOT juvenile. NOT fiction. Number of results: 88.