Reviewer’s report
Title: 
Risk and Protective Factors Associated Mental Health among Female
Military Veterans: Results from the Veterans’ Health Study
Version: 
2 
Date: 
25 Nov 2020
Reviewer's report:
Again the authors have been responsive to Reviewer suggestions and while I
wish I could sign off on the paper, there remain some significant issues that I
believe need to be addressed before it is ready for dissemination.
More significant issues:
1. With all due respect to Reviewer 2, I am at a loss as to why it is important to
include so much text on women veteran's VSO's since there does not seem to be
a direct link to the variables or analyses undertaken in the present study. There
also does not seem to be a direct link to mental health or receipt of care. I
therefore strongly suggest that unless these connections can be made much more
convincingly, all reference to these VSOs be struck from the paper. If there is a
better way to tie VSO's in with the findings, reference to them should only be
made in a future directions comment in the Discussion as there was nothing
about involvement in them assessed in the study so mention of them in the
Introduction is inappropriate.
2. The authors are still not characterizing receipt of mental health care properly.
Because they are examining receipt of mental health care in a binary fashion for
their logistic regressions, it is only appropriate to describe the likelihood of
receipt of care for women (and men) and not "greater" or "higher" care. "Greater
rate (or likelihood) of care" or "higher rate of care" would be ok, however.
3. I should have caught this before, but the demarcation of heavy drinking at 40
drinks per month is problematic for both men and women and at the very least
needs to be supported by a citation. According to current CDC and NIAAA
guidelines, the recommended upper weekly limit for moderate drinking for men
is 14 drinks and for women is 7 drinks. Thus, for men the monthly cut above
which could be considered heavy drinking should be more like > 56 drinks and
for women > 28 drinks. I strongly feel this needs to be corrected even though
heavy drinking (yes/no) is being used as a control variable here.
More minor issues:
4. Pg. 8, line 7; "Lastly, the analyses…." should be changed to something that
directly references that this section is still describing the measures used.
5. Results; The organization of the results text regarding the multivariate models
is confusing and choppy. It is ok to have a summary statement about the overall
findings on each of the four dependent variables, but it is confusing and abrupt to
segue in the same paragraph to the PTSD results.
6. Pg. 12, lines 39-44; The interpretative statement about the sensitivity analyses
isn't appropriate in the results section. Also, although if the sentence is struck
this is moot, the first "your" should be "our."
7. Pg. 12, lines 51-54; The statement about the additional sensitivity analysis is
awkward and also doesn't seem to belong in the results section. 
8. The beginning of the Discussion feels like a jumble of repetitive different
statements about how the present study results are consistent with other study
results and thus it needs work.
9. Pg. 13, lines 41-44; The first sentence of this paragraph describes the critically
important findings regarding women's elevated risk of suicidal ideation along
with greater likelihood of having used mental health care, but these issues aren't
developed and instead the paragraph goes on to talk about gender differences on
demographics. This is not doing the results justice and needs to be remedied.
10. Pg. 14; The discussion of the second sensitivity set of analyses that suggest
there are unmeasured variables in the model seems quite off base to me. In
almost every situation where we are trying to understand what is contributing to
complex psychological phenomena we have the problem of unaccounted
variance as it is impossible to measure everything relevant (with no measurement
error) or to even know what all should be measured. Therefore, the lengthy
discussion (lines 22-39.5) on the imperfect modeling is not helpful and the word
count could be more usefully directed to ideas about other variables the literature
suggests (or the authors' clinical observations suggest) might be important to
examine in future research. I see that the final sentence of this paragraph
mentions some unmeasured constructs, but this feels tagged on as an
afterthought and should be developed further in favor of the lines of text noted
above.
11. Pg.14 paragraph starting line 46; Additionally, the sentence about the lack of
statistical gender difference in lifetime use of mental health services needs to be
reworked. First, it's a null result that could easily have been driven by power or
controlling for age might not have adequately accounted for the vast mean age
differences between the two groups (i.e., the much younger women would
simply have had less time to participate in MH services than the much older
men). Second, it is hard to see how a more complex look at men's and women's
social contexts has anything to do with their likelihood of receiving MH care.
Similarly, the idea of delving further into the two groups' military experiences is
not obviously tied to whether one or the other group is more likely to seek care. I
think that less time spent trying to chase down why null results might be null and
more time contexualizing findings in the literature and fleshing out the
significant findings would benefit the paper and the messaging. Frankly, this
paragraph reads like a jumble of non sequiturs from beginning to end.
12. Pg. 15, line 17; the line doesn't scan well
13. Pg. 15, line 39; same here
14. Pg. 16, final sentence; I am unclear what the point of the final sentence is. If
it's that perhaps information about other countries' healthcare systems that may
be doing a better job treating women veterans could be useful for US healthcare
systems to know about, this should be stated more plainly. However, given that
the study really does not address the quality of the healthcare that the women in
the study received or what they thought about it or whether it did or did not help
address their mental health concerns, the apparent focus of this last sentence
does not track well with the main issues addressed in the paper.
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Is the study design appropriate to answer the research question (including the use
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