Women Veterans with Depression in Veterans Health Administration Primary Care: An Assessment of Needs and Preferences

Women's Health Issues xxx-xx (2016) 1–11

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Original article

Women Veterans with Depression in Veterans Health Administration Primary Care: An Assessment of Needs and Preferences Teri D. Davis, PhD a,b,*, Duncan G. Campbell, PhD c, Laura M. Bonner, PhD d,e, Cory R. Bolkan, PhD f, Andrew Lanto, MA a, Edmund F. Chaney, PhD e, Thomas Waltz, PhD g,h, Kara Zivin, PhD i,j, Elizabeth M. Yano, PhD, MSPH a,k, Lisa V. Rubenstein, MD, MSPH a,l,m a VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California b University of California, Los Angeles School of Medicine, Division of Psychiatry and Behavioral Sciences-Semel Institute, Los Angeles, California c University of Montana, Department of Psychology, Missoula, Montana d VA HSR&D Northwest Center for Outcomes Research in Older Adults, VA Puget Sound Healthcare System, & Geriatric Research, Education and Clinical Center (GRECC), Seattle, Washington e University of Washington, Department of Psychiatry & Behavioral Sciences, Seattle, Washington f Washington State University Vancouver, Department of Human Development, Vancouver, Washington g Department of Psychology, Eastern Michigan University, Ypsilanti, Michigan h Center for Clinical Management Research, Health Services Research and Development Service, VA Ann Arbor Health Care System, Ann Arbor, Michigan i Center for Clinical Management Research (CCMR), VA Ann Arbor Medical Center, Ann Arbor, Michigan j University of Michigan Medical School, Department of Psychiatry, Ann Arbor, Michigan k University of California, Los Angeles School of Public Health, Department of Health Services, Los Angeles, California l University of California, Los Angeles School of Medicine, Division of General Internal Medicine and Health Services Research, Los Angeles, California m RAND Health Program, RAND Corporation, Santa Monica, California

Article history: Received 20 July 2015; Received in revised form 26 July 2016; Accepted 5 August 2016

a b s t r a c t Objective: Depression is the most prevalent mental health condition in primary care (PC). Yet as the Veterans Health Administration increases resources for PC/mental health integration, including integrated care for women, there is little detailed information about depression care needs, preferences, comorbidity, and access patterns among women veterans with depression followed in PC. Methods: We sampled patients regularly engaged with Veterans Health Administration PC. We screened 10,929 (10,580 men, 349 women) with the two-item Patient Health Questionnaire. Of the 2,186 patients who screened positive (2,092 men, 94 women), 2,017 men and 93 women completed the full Patient Health Questionnaire-9 depression screening tool. Ultimately, 46 women and 715 men with probable major depression were enrolled and completed a baseline telephone survey. We conducted descriptive statistics to provide information about the depression care experiences of women veterans and to examine potential gender differences at baseline and at seven month follow-up across study variables. Results: Among those patients who agreed to screening, 20% of women (70 of 348) had probable major depression, versus only 12% of men (1,243 of 10,505). Of the women, 48% had concurrent probable posttraumatic stress disorder and 65% reported general anxiety. Women were more likely to receive adequate depression care than men (57% vs. 39%, respectively; p < .05); 46% of women and 39% of men reported depression symptom improvement at the 7-month

* Correspondence to: Teri D. Davis, PhD, VA Greater Los Angeles Healthcare System, West Los Angeles VAMC, 11301 Wilshire Blvd. 111G, Bldg 500, Room 3233, Los Angeles, CA 90073. Phone: (310) 478-3711 ext. 40920 (Office); fax: 310-268-4933. E-mail addresses: [email protected], [email protected] (T.D. Davis). 1049-3867/$ - see front matter Published by Elsevier Inc. on behalf of Jacobs Institute of Women's Health. http://dx.doi.org/10.1016/j.whi.2016.08.001

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follow-up. Women veterans were less likely than men to prefer care from a PC physician (p < .01) at baseline and were more likely than men to report mental health specialist care (p < .01) in the 6 months before baseline. Conclusion and Implications for Practice: PC/mental health integration planners should consider methods for accommodating women veterans unique care needs and preferences for mental health care delivered by health care professionals other than physicians. Published by Elsevier Inc. on behalf of Jacobs Institute of Women's Health.

Depression continues to be a significant public health concern and one of the leading causes of disability and negative healthrelated consequences in women veterans (Department of Veterans Affairs & Veterans Health Administration, 2010a, 2010b; Yano, Washington, Goldzweig, Caffrey, & Turner, 2003). In the Veterans Health Administration (VA), depression is the most common psychiatric disorder diagnosed in women. For example, recent prevalence estimates of depression in veterans returning from Iraq and Afghanistan range between 30% and 48% for women and 17% and 39% for men (Haskell et al., 2010; Maguen, Ren, Bosch, Marmar & Seal, 2010). These estimates exceed the rates of posttraumatic stress disorder (PTSD) among veterans, which range between 10% and 21% in women and 22% and 33% in men (Grubaugh, Monnier, Magruder, Knapp, & Frueh, 2006; Haskell et al., 2010). Although prior research documents the importance of depression among women veterans, more information is needed on women veterans’ depression care needs generally and in relation to psychiatric comorbidity. Estimates suggest, for example, that 36% of veterans with depression also experience PTSD (Campbell et al., 2007). Other studies of veterans from settings outside of primary care (PC) suggest that approximately 61% of women veterans with depression and 66% of depressed male veterans experience PTSD (Curry, Aubuchon-Endsley, Brancu & Runnals, 2014; Lehavot, Der-Martirosian, Simpson, Sadler & Washington, 2013). How PTSD and other psychiatric comorbidities shape the care needs among depressed women veterans requires additional clarification. Depression is common in PC settings among both men and women, and is often unrecognized. In addition, treatment adequacy, receipt of quality care, and engagement in care are often suboptimal (Department of Veterans Affairs & Veterans Health Administration, 2008; Dwight-Johnson, Sherbourne, Liao & Wells, 2000; Rubenstein et al., 2010). These shortcomings may be particularly significant for women veterans, because a disproportionate number of women veterans delay health care owing to a host of individual and systemic health facility barriers. Systems barriers include limited gender-specific health care services and lack of training among PC clinicians specifically in women’s health (Washington, Bean-Mayberry, Riopelle & Yano, 2011). Lack of quality treatment among depressed patients is a risk factor for loss of employment (Zivin et al., 2012), homelessness (Washington et al., 2010), and the progression of chronic health conditions (Possemato, Wade, Anderson & Ouimette, 2010), all of which may worsen quality of life. Ideally, care planning efforts for women veterans should be informed by evidence from studies that specifically assess the needs, preferences, and service use of clinical samples of women veterans visiting PC who have probable major depression. At present, few such studies exist (Decker, Rosenheck, Tsai, Hoff, & Harpaz-Rotem, 2013). Because women represent the majority of participants in depression treatment studies in non-VA PC settings (DwightJohnson et al., 2000; Dwight-Johnson, Unutzer, Sherbourne, Tang, & Wells, 2001; Wells et al., 2000; Wells et al., 2004),

abundant data are available on women with depression seeking care outside VA. Results from these general population studies suggest that women with depression are overrepresented relative to men; women also often present with comorbid anxiety disorders and tend to prefer psychotherapy to pharmacological treatments (Kessler, 2003; Piccinelli & Wilkinson, 2000). Furthermore, women also seem to experience better clinical outcomes and receive a higher quality of care when mental health services are integrated within PC in comparison with usual care (Dwight-Johnson et al., 2000; Dwight-Johnson et al., 2001; Wells et al., 2000; Wells et al., 2004). Although this information is useful, it may not generalize to the unique population of women veterans seeking VA care. This underscores the significant need for research-based evidence regarding the mental health needs of representative samples of women veterans in VA PC. Women represent a fast growing segment of veterans seeking VA care (Yano et al., 2010). In response to this trend and congressional mandate, VA has supported women’s health with a number of initiatives, including publication of standard clinical requirements for women’s health care, creation of the Women Veterans Health Strategic Health-Care Group, and a requirement that all VA care facilities use women’s health care planners (Department of Veterans Affairs & Veterans Health Administration, 2010a; Yano et al., 2003; Yano et al., 2010). In 2006, VA also invested significantly in PC-mental health integration (MHI) that was later mandated in 2008. The 2008 mandate arose in response to evidence that 20% of VA PC patients present with mental health diagnoses, largely depression related, and to data suggesting that depression screening and treatment provided in PC improves care access and contributes to better clinical outcomes (Campbell et al., 2007; Kirchner et al., 2010; Liu et al., 2009; Liu et al., 2003; Zivin et al., 2010). The PC-MHI initiative currently mandates care management and the co-location of mental health specialists such as psychiatrists, psychologists, and social workers in PC. It also strongly encourages proactive care management for depression and comorbid conditions. Specific PC-MHI planning for women veterans, however, has been minimal, and there remains a significant need for coordination of mental health services for depression and related conditions for women veterans in PC and other VA care settings (MacGregor et al., 2011; Oishi et al., 2011). Two systematic evidence reviews showed that most existing evidence on mental health among women veterans focuses largely on conditions related to military service (e.g., documentation of disproportionate rates of PTSD and military sexual trauma among women compared with men; Bean-Mayberry et al., 2011; Goldzweig, Balekian, Rolon, Yano, & Shekelle, 2006). Additionally, most studies focused on younger patient populations and on women attending specialty mental health care rather than PC. Few studies have focused explicitly on depression in the population of women veterans enrolled in VA PC (Grubaugh et al., 2006; Maguen et al., 2010; Possemato et al., 2010; Seal et al., 2010).

T.D. Davis et al. / Women's Health Issues xxx-xx (2016) 1–11

The work presented herein assesses the demographic characteristics, prevalence of psychiatric comorbidities, and care preferences of men and women veterans with depression seeking treatment in VA PC settings. Given the gaps in what is known about depression care among women veterans, the present study aimed first to estimate the prevalence of depression among women attending VA PC. Second, we assessed for potential gender differences across demographic and illness characteristics, patients’ depression care preferences, patients’ depression care use (mental health specialist and PC health services), and depression treatment adequacy. Methods

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Ultimately, 761 veterans (715 men, 46 women) with probable major depression (Figure 1) agreed to WAVES participation and completed a 50-minute telephone survey that used computerassisted telephone interviewing procedures. Given that a current major depressive episode was an inclusion criterion for WAVES, little is known about those participants who were not eligible to complete the full baseline interview. Follow-up data were collected at 7 months. Baseline and follow-up interviews addressed patients’ clinical experiences, health care needs, health care engagement, and care preferences. The present study examined data from all WAVES patients at baseline and 7-month follow-up, including those from WAVES sites that implemented depression collaborative care management and those from “control” sites that did not.

Setting and Sample Measures This study is based on secondary analyses of data collected for the Well-being Among Veterans Enhancement Study (WAVES), a cluster-randomized evaluation of VA collaborative care management for depression in PC. WAVES included patients from 10 VA PC clinics in five states across three geographical VA administrative regions (Chaney et al., 2011). The primary aim of WAVES was to examine whether care processes and patient outcomes differed between the seven clinics that implemented collaborative care management and the three control clinics that did not. WAVES clinics used between 4 and 13 PC providers each and served between 3,900 and 13,000 patients annually (Chaney et al., 2011). Institutional Review Boards at the University of Washington and participating VA sites approved all WAVES procedures. To facilitate recruitment of a study sample similar to the population of patients with major depression seen in VA PC practice, WAVES used a visit-based sampling procedure that identified all patients with an upcoming PC appointment at one of the participating clinics during an enrollment time window. Patients were contacted by a contracted survey research firm by mail and were provided a study description and options for study refusal. Ten days after mailing the descriptive information, interviewers from the survey research firm contacted patients and initiated study inclusion screening using computer-assisted telephone interviewing procedures. Patients were eligible for WAVES if they had probable major depression based on the Patient Health Questionnaire-9 (PHQ-9), a self-report measure of major depressive episode symptomatology based on the Diagnostic and Statistical Manual of Mental Disorders-IV criteria (Kroenke, Spitzer & Williams, 2001). The PHQ-9 presents the nine diagnostic criteria for depression, and respondents indicate the 2-week frequency with which they experience each symptom on a scale ranging from 0 (“not at all”) to 3 (“every day/ nearly every day”). Previous work with the measure (Kroenke et al., 2001) indicates that sum scores on the PHQ-9 of 10 and greater identify a major depressive episode with high sensitivity (0.88) and specificity (0.88). Determination of WAVES eligibility on the depression criterion was a two-step process. Interviewers first screened 10,929 potential participants for anhedonia and/or depressed mood with the first two items of the PHQ-9. On this abbreviated depression measure, the PHQ-2 (Whooley, Avins, Miranda & Browner, 1997), scores of 3 and higher denoted a positive screen. Those patients with positive screens continued on to complete the full PHQ-9. Participation rates among women and men in WAVES were similar, with somewhat lower refusal rates among women (Fig. 1).

Demographic characteristics Demographic information included gender, age, ethnicity (White, African American, all others), relationship status, education, and employment status. Physical health A single Health Status Questionnaire (Kazis et al., 1999) item asked patients to describe their general health. Specifically, patients described their health using one of five responses, ranging from “excellent” to “poor.” This single-item indicator of global health is used regularly in health research, and recent work suggests that the reliability and validity evidence of the measure compares favorably with multi-item scales of general health (Macias, Gold, Ongur, Cohen & Panch, 2015). Psychiatric Comorbidity Factors Chronic depressed mood The WAVES survey measured the chronicity of depressed mood using two questions adapted from the Mental Health Awareness Project, a National Institute of Mental Health study of depression care quality improvement (Rubenstein, Parker, & Meredith, 2002). Following the diagnostic criteria for dysthymic disorder, one question asked whether or not respondents had experienced a period of 2 years or more when they felt depressed or sad most days; a second question asked about whether or not respondents had experienced a 2-year period of depressed mood during which they did not experience a two month or longer period during which they felt “OK.” Patients who responded “yes” to both questions were coded as having chronic depressed mood/dysthymia. Probable PTSD The Primary Care PTSD Screen (Prins et al., 2003) assessed the presence of four key PTSD symptoms in the previous month. Primary Care PTSD Screen scores range from 0 to 4; previous research suggests that the scale has good test–retest reliability (r ¼ .83; Prins et al., 2003). In previous work, scores of 3 and above identified PTSD with acceptable sensitivity (0.78) and specificity (0.89; Prins et al., 2003). Scores of 3 and greater indicated probable PTSD in WAVES and the present study. General anxiety A single face valid question asked participants to indicate (yes or no) whether they felt anxious much of the time over the past 6 months. Positive responses indicated presence of general anxiety.

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T.D. Davis et al. / Women's Health Issues xxx-xx (2016) 1–11

Figure 1. Sampling diagram. Abbreviations: PC, primary care; PHQ, Patient Health Questionnaire.

Alcohol abuse The first three items of the Alcohol Use Disorders Identification Test (AUDIT-C) compose a three-item screen with good validity evidence for identification of alcohol misuse among VA patients (Bradley et al., 2007; Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998). The AUDIT-C assesses alcohol consumption frequency (from 0 [never] to 4 [4 times a week]), number of drinks typically consumed while drinking (0 [1–2] to 4 [10]), and frequency of overconsumption (0 [never] to 4 [daily or almost daily]). Total scores on the AUDIT-C range from 0 to 12. In previous research by Bradley et al. (2007), AUDIT-C scores of 4 and greater identified alcohol use disorders with high sensitivity and specificity (0.88 and 0.75, respectively, in men, and 0.71 and 0.92, respectively, in women). We identified alcohol misuse with AUDIT-C scores of 4 and greater in the present analyses. Suicidal ideation The final PHQ-9 item assesses frequency of thoughts about suicide or self-harm. Any response to this item other than “not at all” suggests that respondents experience thoughts about suicide with frequencies ranging from occasionally to every day/nearly every day. Previous research demonstrates that this single item indicator predicts risk of suicide attempts and death by suicide

(Simon et al., 2013) as well as psychiatric complexity and possible treatment resistance (Bauer, Chan, Huang, Vannoy, & € tzer, 2012). For the present study, any response to this item Unu other than 0 indicated the presence of suicidal ideation. Depression and General Care Received, Treatment Preferences, and Outcomes Self-reported health care use Participants provided self-report of their use of several different health care services. For example, patients reported whether or not they had visited a mental health specialist within 6 months before baseline. Those reporting this care were then asked what provider type they had seen (i.e., psychiatrist, psychologist, nurse, social worker, or other). Patients who had not seen a specialist within 6 months were asked if they had ever seen a mental health specialist. Self-reported mental health care experiences in PC Patients who reported a PC visit within the 6 months before baseline indicated whether their providers had asked during their most recent visit about sadness or depression, alcohol use, and/or suicide. Patients also indicated whether or

T.D. Davis et al. / Women's Health Issues xxx-xx (2016) 1–11

not their providers had recommended counseling for emotional problems, made a referral to a mental health specialist, and/or initiated or changed a medication for emotional problems. Adequate depression care The adequate care variable is a binary (yes/no) measure developed for the WAVES study, based on prior research (Wells et al., 2000). We defined adequate care as 1) having four or more visits with a mental health specialist in the previous 6 months and/or 2) having taken an antidepressant (selective serotonin reuptake inhibitor or bupropion) as prescribed for more than 25 days in the past month or taken for more than 25 days over more than 3 consecutive months when surveyed at baseline. Depression treatment preferences At baseline, we assessed patients’ openness to receiving care from different depression treatment provider types with a series of questions that used the stem, “If you were depressed or had other emotional troubles and could choose who would help you, how likely would you be to choose each of the following.?” Using a 5-point scale (1 [very likely] to 5 [very unlikely]), participants indicated whether they would choose a PC physician, a psychiatrist, another mental health specialist (i.e., psychologist, social worker or psychiatric nurse), and/or a spiritual counselor. We dichotomized participants’ responses, with very likely and likely recoded to yes and the remaining three scale points recoded to no. Depression outcomes/symptom reduction Improvement in depression was determined by a decrease in self-reported depression symptoms based on scores from the PHQ-9 between baseline and the 7-month follow-up. Patients who no longer met the criterion for probable depression (PHQ-9 sum < 10) at the 7-month follow-up were identified as having experienced symptom reduction. Psychosocial Factors Social support Eight items from the Medical Outcomes Study Social Support Scale (Sherbourne & Stewart, 1991) measured social support at baseline. These items composed social support indicators in the present work and in previous work, including the Mental Health Awareness Project (Rubenstein et al., 2002). For each item, participants indicated how much they could count on someone to provide specific elements of support. Items assessed emotional/affective aspects of social support (e.g., “give you a hug when you want one”), and assessed tangible aspects of social support (e.g., “take you to the doctor if you needed it”). Participants responded to each item with a 5-point scale ranging from 0 (not at all) to 4 (completely). Separate mean scores were created for emotional/affective social support and tangible social support. Higher mean scores reflected higher perceived availability of social support (Sherbourne & Stewart, 1991). Satisfaction with care Participants were asked to indicate the degree to which they were satisfied with the health care they received in the 6 months preceding baseline. They reported their degrees of satisfaction with the health care they received for physical and emotional

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problems separately, using a 5-point scale ranging from very satisfied to very dissatisfied. To facilitate presentation, we reduced patients’ satisfaction ratings to a 3-point scale (satisfied, neutral, dissatisfied). Very satisfied and satisfied ratings were recoded as satisfied, and dissatisfied and very dissatisfied ratings were recoded to dissatisfied. Statistical Analysis Survey data were adjusted for population weights derived to reflect the sampling frame of VA PC users (e.g., using gender, age and probability of participant enrollment). Weighting procedures are available upon request. To better understand the gender-specific needs of depressed women, we tested differences between men and women in depression severity, psychiatric comorbidities, health care, and social support; these comparisons used t-tests for continuous measures and c2 statistics for categorical measures. Given the exploratory nature of the study, we did not adjust the p value for multiple comparisons. Computer-assisted telephone interviewing procedures resulted in minimal missing data, precluding a need for missing value imputation. Analyses were conducted using Stata version 11.1 (StataCorp, College Station, TX [StataCorp, 2009]). Results Figure 1 presents sampling results. Of the total 10,929 patients, 2,186 (20.0%) screened positive on the PHQ-2. Proportionately more women than men screened positive (26.9% or 94/ 349 vs. 19.8% or 2092/10,580, respectively). In the following step, 2,110 of the PHQ-2 screen-positive patients were administered the remaining PHQ-9 items. In all, 62.2% of patients who completed the full PHQ-9 scored at or above the screening threshold for a probable major depressive episode (75.3% or 70/ 93 for women and 61.6% or 1,243/2,017 for men). After accounting for patients who were contacted and/or screened positive and chose not to continue with screening or the full PHQ-9, the prevalence of depression among the VA PC attendees was 20.1% (348/70) for women and 11.8% (1,243/10,505) for men. Women and men did not differ in depression severity, as measured by the PHQ-9 (Women: M ¼ 16.4, SD ¼ 3.8; Men: M ¼ 15.8, SD ¼ 4.3; t (759) ¼ 0.91, p ¼ .36, d ¼ 0.14, 95% CI, 0.16 to 0.44). Demographic and Psychiatric Comorbidity Characteristics Table 1 depicts sample characteristics and comparisons by gender for demographic variables. Women were younger than men: mean age 52.1 versus 60.8 years, t (759) ¼ 4.90, p < .001, d ¼ 0.75, 95% CI, 0.44 to 1.05, and more likely to identify as ethnic minorities. Women were also better educated than men, more likely than men to be employed, and less likely than men to be married or living as married. Although the majority of respondents reported poor to fair health, women (30.4%) were more likely than men (18.9%) to report good to excellent health. Table 2 depicts the mental health comorbidity in this sample. No differences were observed in the proportions of men and women who had positive indicators for psychiatric comorbidities’. As noted, however, probable major depression among screened patients was more frequent among women relative to men. Furthermore, more women than men reported chronic depressed mood (37.0% vs. 26.5%, respectively) and probable PTSD (47.8% vs. 38.0%, respectively). Suicidal ideation was

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T.D. Davis et al. / Women's Health Issues xxx-xx (2016) 1–11

Table 1 Demographic Characteristics of Veterans with Probable Major Depression Visiting Primary Care

Age, mean (SD) Ethnicity (%) White African American Other Marital status (%) Married/cohabitating Not married Education (%)
Table 3 Mental Health Care Experiences Women (%)

Women

Men

p

52.1 (14.0)

60.8 (11.6)

<.001 .01

78.3 4.3 17.4

85.3 8.1 6.0 <.001

32.6 67.4

61.8 38.2

0.0 21.7 19.6 28.3 30.4

10.9 40.3 12.0 25.7 11.0

26.1 13.0 41.3 13.0 6.5

16.4 9.1 41.1 30.8 2.5

30.4 69.6

18.9 81.0

<.001

.04

.06

Note: Percentages are based on n ¼ 46 for women and n ¼ 715 for men. Respondents were able to refuse to answer questions. As a result, some of the demographic category totals are less than 100%. Significance for age was determined by t test, all others were based on c2 tests.

present for more than 25% of women veterans with probable depression, and 15% screened positive for alcohol misuse. Of the women surveyed, 65% reported generalized anxiety. Mental Health Care Experiences Table 3 displays mental health care experiences by gender. At baseline, women veterans were more likely than men to report having received adequate depression care (p ¼ .02). Specifically, more women veterans met the care quality benchmark (four visits) for mental health specialist care than men (p ¼ .004), although no differences were found by gender for meeting the care quality benchmarks for antidepressant care. Consistent with their higher rates of treatment, 45% of women and 39% of men reported depression symptom improvement at the 7-month follow-up, although this difference was not significant. In terms of mental health care visits, women veterans with depression were significantly more likely than men to report a mental health specialist visit within the 6 months before baseline (p ¼ .002), as well as to report a last mental health specialist visit occurring more than 6 months before baseline (p ¼ 003). When adjusted for age, the gender difference remained

Table 2 Mental Health Comorbidities Positive Screen

Women (%)

Men (%)

p

Dysthymia/chronic depressed mood Suicidal ideation PTSD Generalized anxiety Alcohol misuse

37.0 26.1 47.8 65.2 15.2

26.5a 32.1b 38.0 63.9c 23.8a

.12 .40 .19 .85 .18

Note: Percentages are based on n ¼ 46 for women and the n for men ranged from 705 to 715 (a ¼ 709, b ¼ 705, c ¼ 714). Respondents were able to refuse to answer questions. Significance was determined by c2 tests.

Adequate depression care No 43.5 Yes 56.5 Four or more mental health specialist visits in past 6 months No 69.6 Yes 30.4 Antidepressant care quality benchmark meta No 36.7 Yes 63.3 Depression outcomes/symptom 45.5 b reduction at 7 months Any mental health specialist contact in past 6 months? No 32.6 Yes 67.4 If no, have you ever had contact c with a mental health specialist? No 26.7 Yes 73.3 If yes, specialist seen (contact in last 6 months) Psychiatrist 58.1 Psychologist 35.5 Nurse 38.7 Social work 29.0 PC-related mental health care in last 6 monthsd PC asked about sadness or 43.6 depression PC asked about alcohol use 53.8 PC asked about suicidal thoughts 38.5 PC recommended counseling for 15.8 emotional problems PC provided a prescription for 30.8 emotional problems

Men (%)

p .02

60.7 39.0 <.01 84.8 14.5 .89 35.4 64.6 38.6

.43 <.01

55.9 43.4 <.01 64.6 35.4 75.2 45.5 29.0 33.5

.05 .24 .29 .60

43.1

.96

52.3 34.4 13.3

.85 .61 .66

32.2

.86

Note: Percentages are based on n ¼ 46 for women and n ¼ 715 for men unless otherwise noted. aPercentages are based on n ¼ 30 for women and n ¼ 347 for men reporting an active antidepressant prescription; bpercentages are based on n ¼ 33 for women and n ¼ 513 for men who completed the PHQ-9 at a 7-month follow-up permitting evaluation of an improvement in their depression scores; c percentages are based on n ¼ 15 women and n ¼ 404 men reported not having mental health specialist care in the past 6 months and responded to the question regarding whether they have ever received mental health specialist care; dowing to a small percentage of participants reporting being uncertain whether these activities had occurred percentages for women are based on an n range of 38–39 and a range of 589–603 for men.

significant for completing a mental health specialist visit any time before or within the past 6 months. Among veterans who had seen a mental health specialist within the past 6 months, depressed women were less likely than depressed men to be seen by a psychiatrist (p ¼ .05). There were no other differences for the other mental health specialty care provider categories. Similarly, as presented in the bottom section of Table 3, no differences by gender were found for key mental health care activities provided by PC physicians for those receiving PC in the last 6 months. Depression Care Preferences As shown in Table 4, only 48% of women veterans with probable major depression compared with 68% of men (p < .01) preferred depression care from a PC provider. Although there were no gender differences in care preferences for psychiatrists, spiritual counselors, and other mental health specialists (i.e., psychologist, social worker, nurse), the majority of both genders

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Discussion

Table 4 Treatment Preferences Women (%)

Men (%)

p

Prefer PC physiciana Likely/somewhat likely 47.8 67.8 <.01 Uncertain/unlikely 52.2 32.2 Prefer psychiatristb Likely/somewhat likely 60.9 64.5 .62 Uncertain/unlikely 39.1 35.5 c Prefer spiritual counselor Likely/somewhat likely 43.5 47.5 .59 Uncertain/unlikely 56.5 52.5 Prefer another mental health specialist (i.e., psychologist, social worker, nurse)b,d Likely/somewhat likely 68.9 66.9 .78 Uncertain/unlikely 31.1 33.1 Note: Percentages are based on n ¼ 46 for women and n ¼ 715 for men unless otherwise noted. aPercentages are based on n ¼ 702 for men; bpercentages are based on n ¼ 710 for men; cpercentages are based on n ¼ 713 for men; d percentages are based on n ¼ 45 for women.

preferred care from psychiatry and other mental health specialists. Sizable minorities of both women and men preferred care from a spiritual counselor.

Care Satisfaction and Social Support Data on care satisfaction and psychosocial factors, including family involvement in care and social support, are presented in Table 5. Although there were no differences between women and men in their satisfaction with health care for physical and emotional problems, lower proportions of women were satisfied with care for both types of problems. Women were also less likely to report satisfaction with their providers’ involvement of their family in their care, although this difference also was not significant. Outside of professional care, women reported significantly lower social supports than men. These differences were found with both tangible support, t (759) ¼ 3.68, p < .001, d ¼ 0.56, 95% CI, 0.26 to 0.86, and emotional support, t (759) ¼ 2.45, p ¼ .01, d ¼ 0.37, 95% CI, 0.07 to 0.67. Table 5 Care Satisfaction and Social Support Women (%) Satisfied with health care for physical problems Satisfied Neutral Dissatisfied Satisfied with health care for emotional problems Satisfied Neutral Dissatisfied Satisfied with provider’s involvement of family in care Satisfied Neutral/dissatisfied Social support, mean (SD) Tangible support Emotional support

Men (%)

p .21

60.9 17.4 21.7

72.3 11.0 16.2 .10

45.7 28.3 21.7

60.1 17.8 17.5 .24

47.8 45.7

57.6 38.2

3.1 (1.3) 3.1 (1.2)

3.8 (1.2) 3.7 (1.1)

<.001 .01

Note: Percentages are based on n ¼ 46 for women and n ¼ 715 for men. Respondents were able to refuse to answer questions. As a result, some of the satisfaction category totals are less than 100%. Significance for social support was determined by t test, all others were based on c2 tests. Tangible support, t (759) ¼ 3.68, p < .001, d ¼ 0.56, 95% confidence interval, 0.26–0.86. Emotional support, t (759) ¼ 2.45, p ¼ .01, d ¼ 0.37, 95% confidence interval, 0.07–0.67.

Women represent a growing segment of veterans seeking VA PC (Yano et al., 2010). Using a PC visit-based sampling strategy and mental health screening tools, including those recommended for routine VA practice (Kirchner, Curran & Aikens, 2004; VA/DOD, 2010, 2015), we found that the prevalence of depression among veterans cared for in VA PC clinics in five states was 20% among women and 12% for men. These results highlight the widely acknowledged need to integrate mental health care into PC settings, especially for women. The need to move from a separate focus on mental health specialty care for depression and other conditions to a broader population focus has resulted in the PC-MHI initiative within VA. Despite the long-standing evidence of integrating depression care within PC, minimal detailed planning for women veterans within broader VA PC-MHI initiatives has been carried out. This exploratory study documented key descriptive information on depression prevalence, psychiatric comorbidities, psychosocial characteristics, engagement in specific mental health care, and care preferences among women with depression visiting VA PC. These data can serve as a basis for PC-MHI planning going forward. Although much previous work on women veterans shows disparities in quality of caredwith women typically receiving lower quality care than mendquality of depression care was equivalent for women and men in the present study. Our results suggest that depression detection, treatment, and outcomes for women were as good or better than among men, with women more likely to receive adequate care, as likely to show symptom improvement at 7 months, and more likely to pursue care from a mental health specialist. Although these results may reflect both positive engagement in seeking care and access to mental health care, only 45% of women reported improvement at the 7month follow-up. We offer that the abilities of women veterans to take advantage of VA treatment options should build optimism regarding the benefits of investing in VA depression treatment for this vulnerable population. We maintain that further investment should continue to target improved treatment entry and engagement among women veterans. It is likely that care for women veterans would be enhanced through continued efforts to identify patients in need of care in the first place and through assessment strategies to identify those patients who initiate care but engage in it partially. Identifying women veterans with depression should continue to employ the standardized screening methods (i.e., PHQ-2) that are mandated by VA care policy (VA/DOD, 2016). In an attempt to cast a wide net among women, initial screening thresholds for depression should emphasize sensitivity by employing low cutoffs for positive screens. For example, in contrast with using the standard VA clinical practice cut score of 3 and higher, which was used to identify patients with depression in the present study, Arroll et al. (2010) note that a PHQ-2 score of 2 and higher should increase overall depression detection. Although a lower cut score on the PHQ-2 may lead to a higher number of false positives, these patients could be identified with relative ease through follow-up testing with the full PHQ-9 (Arroll et al., 2010). Furthermore, and consistent with recommendations drawn from research in different populations (Darwin, McGowan & Edozien, 2016; Ganzini et al., 2013), initial mental health screening among women veterans should be conducted by a familiar care provider in an “enabling environment” that focuses on patient centeredness. Caring and empathic clinicians should evaluate patients

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who screen positive in more extensive encounters that examine diagnostic specificity and facilitate sensitive follow-up on critical clinical concerns like suicidal ideation and/or intent (Ganzini et al., 2013). To maximize care engagement, PC providers should focus on systematic reassessment and follow-up evaluation of those patients who start care. Reassessment would facilitate detection of the 55% of women who do not respond fully to treatment and would generate reasons for treatment nonadherence, partial engagement and adjustments in care management among these patients. In effect, improved understanding of why some patients are not responding and/or engaging in treatment should promote care modifications and, consequentially, increase depression treatment engagement. Our results indicate that a considerable number of women with depression in PC present with complicated mental health concerns, including comorbid general anxiety, PTSD, and chronic depression/possible dysthymia. These findings are consistent with results among civilian women with depression (DwightJohnson et al., 2000; Dwight-Johnson et al., 2001; Wells et al., 2000; Wells et al., 2004) and with results from military PC settings (Curry et al., 2014; Lehavot et al., 2013). Depressed women veterans are burdened by co-occurring PTSD, anxiety, and chronic depression at rates that seem to be higher than those observed among veterans who are men. In response to these findings, we suggest that women veterans who screen positive for depression in PC settings should be assessed thoroughly for suicidality, anxiety, PTSD, and alcohol misuse. Depression treatment care plans will need to specifically integrate strategies for managing comorbid anxiety, PTSD, and/or alcohol misuse when present. These plans should aim to avoid complications such as the well-known risks of dependence on benzodiazepines among patients with anxiety and the related risks of benzodiazepine use by patients with suicidal ideation and alcohol misuse. We also find that there is room for improving treatment coordination and that a “one-size fits all” approach to care for women veterans with depression may not be clinically effective, given their substantial comorbidities. We recommend that planning for PC-MHI care should better accommodate the clinical characteristics and care preferences we observed among our sample of women veterans. Recent studies suggest, for example, that treating depression and PTSD within PC-MHI settings is effective (Hoerster et al., 2015). Consistent with findings like these and stepped-care principles, women veterans with the most complex symptoms and circumstances should be considered for time-limited problem-focused psychotherapy in PC when it is available; referral to mental health specialty care should be considered when it is not. Ultimately, the availability of integrated mental health specialty services and consultation for these comorbid conditions and complex symptom presentations in the context of PC-MHI are critical. Women veterans with depression in the present study also showed a significant strength, including having higher rates of employment than depressed men and reported similar rates of disability status. These findings are somewhat surprising given the high rates of probable PTSD and of chronic depression, both of which often result in work loss and social isolation. Although we are unable to determine with certainty the causal factors behind the employment finding, it is important to note that the men in our sample were older than the women and that higher proportions of men were retired. Our finding that women veterans were more likely to report lower levels of social support in the present study was related, in part, to the fact that women were less likely than men to be

partnered (i.e., married/living as married). Regardless, social support is widely recognized as a protective factor among depressed individuals (Bolkan et al., 2013) and should be considered in integrated care planning for women veterans. Social support, in particular, deserves attention given our finding that fewer than one-half of the women were satisfied with the degree to which their VA clinicians involved family members in their health care. In response to these findings, we suggest that it is critical for care providers to assess the sources of tangible and emotional support available in the home or community for depressed women veterans. Treatment and care planning for those with low levels of support may need to focus on building alternative support structures, such as clinic-based peer support groups for women with depression within PC settings. Although the majority of depressed women and men completed adequate antidepressant treatment, significantly more women than men achieved our benchmark for minimally adequate contact with mental health specialists. Consistent with being more likely to receive minimally adequate care overall than men, a greater percentage of women reported depressive symptom improvement at follow-up, although this was not significant. Exploring women’s treatment preferences in more detail, our findings suggest that fewer women compared with men preferred depression care from physicians (PC provider or psychiatrist). It is possible that women may prefer non-physician/ non-medication prescribing specialists because they perceive non-physician specialists as more likely to provide psychotherapy, in addition to or instead of, treatment with medications. These preferences may also be driven in part by the complex and psychiatrically comorbid presentations of many women’s depression experiences. Women patients may believe, for example, that their circumstances could be addressed best by mental health specialists who provide psychotherapy. Given our data, we suggest that patients’ care preferences should be explored thoroughly at the beginning of treatment. To the degree possible, attempts should also be made to provide preferencematched care, because this demonstrates an association with improved depression care outcomes (Lin et al., 2005). At the systems level, future planning for PC-MHI initiatives should focus on the depression care characteristics and preferences we observed among our sample of women veterans. Along these lines, it is informative to note that a recent systematic review of collaborative care for depression, one of VA’s PC-MHI strategies, suggests that collaborative care approaches that include psychological treatment components, alone or in addition to medication, have the greatest impact on depressive symptoms (Coventry et al., 2014). We acknowledge that patients’ preferences for particular treatment(s) may not align with the actual availability of treatments across all VA sites. In these cases, we recommend that available treatment options should be explored with women veterans and that they be closely monitored for clinical improvement. We also suggest that PC providers receive training focusing on the mental health needs and preferences of women veterans. Further confirmation and corroboration of these results in future research would support VA efforts to expand the availability of depression treatment options for women beyond antidepressants. Limitations Our study has some important limitations. First, it was part of a larger investigation of the VA’s implementation of collaborative

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care management for depression with little specific attention to women veterans. Data were collected between 2003 and 2006; this period was before the large-scale all-VA PC-MHI initiatives that began in 2007. New studies of PC depression screen-positive patients would provide valuable follow-up information on treatment and its results for women within these initiatives. In addition, although our sample resulted from screening more than 10,000 veterans and included multiple care sites from five different states, it was not a national study of all veterans. At the same time, few studies have evaluated veterans visiting diverse PC sites that are systematically screened and assessed for probable major depression. Often, depression studies have referenced patients with an electronically documented diagnosis of depression or patients visiting mental health specialty services. Last, we relied on retrospective self-report data gathered by telephone. As in any study based on retrospective self-report, it is possible that patients’ reports of their care and clinical experiences were imperfect reflections of their actual experiences. At the same time, however, our data were collected in ways that were similar to strategies used in other PC-based VA studies, and we maintain that self-report survey data are better able to characterize many of the psychosocial variables we examined than administrative data drawn from patients’ clinical records (Davis, Deen, BryantBedell, Tate, & Fortney, 2011; Tourangeau, Rips, & Rasinski, 2000). Although methods to reduce bias were used in the present study (e.g., use of questions with good reliability and validity evidence when available, topic saliency, confidentiality and privacy assurances, careful selection and training of interviewers, etc.), it cannot be eliminated altogether. Further, our use of selfreport methods to assess health care service use (e.g., PC visits) has limitations and carries other potential biases in comparison with administrative data. Implications for Practice and/or Policy Our findings suggest that, to achieve optimal depression care for women veterans, attention should be placed on their high levels of psychiatric comorbidity, their low levels of social support, and their needs relative to maintaining employment. Attention to their preferences for care providers other than physicians and the utility of psychological treatments, with and without medication, are also warranted. Our findings may encourage PC-MHI care planners and clinicians to consider expanding the options for depression care to include a broader set of resources among women. Conclusion This study is one of the first to examine the specific depression care needs and preferences of a representative clinical sample of women veterans in VA PC across multiple sites and multiple states. Our study offers a starting point for future indepth analysis of the needs of women veterans with depression. Moving forward, efforts should be directed to better understand how access to a wider range of mental health resources in PC may better manage women’s needs for depression care. Further, our findings also highlight the importance of integrated mental health care in PC for women veterans, given their high prevalence and complexity of depression in these settings. Finally, despite the generally better results for women than for men with depression in this study, more than 40% of women did not receive adequate care and more than 40%

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remained depressed 7 months later. Although our findings provide promising evidence for women veterans’ depression care, more work is certainly needed to better understand how our findings may be utilized in coordinating depression care for women veterans within PC settings moving forward. Acknowledgments This project was funded by the Department of Veterans Affairs (VA) Health Services Research and Development Service (HSR&D) and the VA Quality Enhancement Research Initiative (QUERI) (Project nos. MHI 99-375, MNT 01-027, MHQ 10-06, RRP 12-175). The views expressed here are those of the authors and do not necessarily represent the position or policy of the Department of Veterans Affairs, the United States Government, and the authors’ other institutions. Conflicts of Interest: Drs. Davis, Bonner, Chaney, Waltz, Zivin, Yano and Rubenstein are employed by the Department of Veterans Affairs and have received VA research grant funding. None of the coauthors has specific conflicts of interests related to the manuscript. References Arroll, B., Goodyear-Smith, F., Crengle, S., Kerse, N., Fishman, T., Falloon, K., & Hatcher, S. (2010). Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Annals of Family Medicine, 8, 348–353. Bauer, A. M., Chan, Y., Huang, H., Vannoy, S., & Unutzer, J. (2012). Characteristics, management, and depression outcomes of primary care patients who endorse thoughts of death or suicide on the PHQ-9. Journal of General Internal Medicine, 28, 363–369. Bean-Mayberry, B., Yano, E., Washington, D., Goldzweig, C., Batuman, F., Huang, C., & Shekelle, P. G. (2011). Systematic review of women veterans’ health: Update on successes and gaps. Women’s Health Issues, 21, S84–S97. Bolkan, C. B., Bonner, L. M., Campbell, D. G., Lanto, A., Ziving, K., Chaney, E., & Rubenstein, L. V. (2013). Family involvement, medication adherence, and depression outcomes among patients in Veterans Affairs primary care. Psychiatric Services, 64(5), 472–478. Bradley, K. A., DeBenedetti, A. F., Volk, R. J., Williams, E. C., Frank, D., & Kivlahan, D. R. (2007). AUDIT-C as a brief screen for alcohol misuse in primary care. Alcoholism: Clinical and Experimental Research, 7, 1208–1217. Bush, K., Kivlahan, D., McDonell, M., Fihn, S., & Bradley, K. (1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158(16), 1789–1795. Campbell, D. G., Felker, B. L., Liu, C. F., Yano, E. M., Kirchner, J. E., Chan, D., . Chaney, E. F. (2007). Prevalence of depression-PTSD comorbidity: Implications for clinical practice guidelines and primary care-based interventions. Journal of General Internal Medicine, 22(6), 711–718. Chaney, E., Rubenstein, L., Liu, C., Yano, E., Bolkan, C., Lee, M., . Uman, J. (2011). Implementing collaborative care for depression treatment in primary care: A cluster randomized evaluation of a quality improvement practice redesign. Implementation Science, 6, 121. Coventry, P. A., Hudson, J. L., Kontopantelis, E., Archer, J., Richards, D. A., Gilbody, S., . Bower, P. (2014). Characteristics of effective collaborative care for treatment of depression: A systematic review and meta-regression of 74 randomised controlled trials. PLOS One, 9, 1–14. Curry, J., Aubuchon-Endsley, N., Brancu, M., Runnals, J., & VA Mid-Atlantic MIRECC Women Veterans Research Workgroup, VA Mid-Atlantic MIRECC Registry Workgroup, Fairbank John A (2014). Lifetime major depression and comorbid disorders among current-era women veterans. Journal of Affective Disorders, 434–440. Davis, T. D., Deen, T., Bryant-Bedell, K., Tate, V., & Fortney, J. C. (2011). Does minority racial-ethnic status moderate outcomes of collaborative care for depression? Psychiatric Services, 62, 1282–1288. Darwin, Z., McGowan, L., & Edozien, L. C. (2016). Identification of women at risk of depression in pregnancy: Using women’s accounts to understand the poor specificity of the Whooley and Arroll case finding questions in clinical practice. Archives of Womens Mental Health, 19, 41–49. Decker, E., Rosenheck, A., Tsai, J., Hoff, R., & Harpaz-Rotem, I. (2013). Military sexual assault and homeless women Veterans: Clinical correlates and treatment preferences. Women’s Health Issues, 23(6), 373–378. Department of Veterans Affairs, Veterans Health Administration. (2010a). Sourcebook: Women Veterans in the Veterans Health Administration Volume 1

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Author Descriptions Teri D. Davis, PhD, is a postdoctoral fellow in women’s health with VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System and University of California, Los Angeles School of Medicine, Division of Psychiatry and Behavioral Sciences-Semel Institute, Los Angeles, CA.

Duncan G. Campbell, PhD, is an associate professor, University of Montana, Department of Psychology, Missoula, MT.

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Laura M. Bonner, PhD, is a health services research scientist with VA HSR&D Northwest Center for Outcomes Research in Older Adults, VA Puget Sound Healthcare System, & Geriatric Research, Education and Clinical Center (GRECC), Seattle, WA and the University of Washington, Department of Psychiatry & Behavioral Sciences, Seattle, WA.

Kara Zivin, PhD, is a health services research scientist with the Center for Clinical Management Research, Health Services Research and Development Service, VA Ann Arbor Health Care System and the Center for Clinical Management Research (CCMR), VA Ann Arbor Medical Center, Ann Arbor, MI.

Cory R. Bolkan, PhD, an associate professor, Washington State University Vancouver, Department of Human Development, Vancouver, WA.

Elizabeth M. Yano, PhD, MSPH, is a health services research scientist with VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System and University of California, Los Angeles School of Public Health, Department of Health Services, Los Angeles, CA.

Andrew Lanto, MA, is a statistical analyst with VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA. Edmund F. Chaney, PhD, is a professor with the University of Washington, Department of Psychiatry & Behavioral Sciences, Seattle, WA. Thomas Waltz, PhD, is an assistant profession with Eastern Michigan University, Department of Psychology, Ypsilanti, MI.

Lisa V. Rubenstein, MD, MSPH, is a health services research scientist with VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System and University of California, Los Angeles School of Medicine, Division of General Internal Medicine and Health Services Research, Los Angeles, CA.