Reviewer’s report
Title: 
Risk and Protective Factors Associated Mental Health among Female
Military Veterans: Results from the Veterans’ Health Study
Version: 
0 
Date: 
11 Feb 2020
Reviewer's report:
In this study, the authors use data from a random sample of 1,730 U.S. military
service veterans utilizing non-VA healthcare in Pennsylvania to assess the
prevalence of mental health disorders and treatment seeking. The major findings
of the study focus on women veterans' greater risk for lifetime PTSD, lifetime
depression, and lifetime suicidal thoughts, and their lower psychological
resilience, use of psychotropic medicines, and psychiatric services compared to
men. Given that, as the authors point out, women are the fastest growing
demographic group in the military, the study's results are important for better
serving the behavioral health needs of this population. However, the analysis
focuses mostly on mental health disorders and speaks little to treatment
differences between women and men. 
I have a few suggestions for strengthening the study and manuscript, which I list
below.
Introduction
1. In the introduction, you cite the percentage of women who are active duty
forces and the projected percentage of the veteran population who will be women
by 2042, but it would be great if you could also cite the percentage of the current
veteran population who are women, since this is your focus population.
2. You say the purposes of the study are to determine if "(1) trauma experiences
(both military and 
non-military) and psychological well-being differ between male and female
veterans and (2) if we can 
explain the well-being differences using multivariate statistical analysis
controlling for confounding and other risk factors." It seems you also are using
this study to assess sex differences in treatment seeking, based on your abstract
and results. Should this be listed as a third aim? 
3. The authors justified their use of a largely non-VA sample well. I think
understanding mental health disorders and treatment use in this population
provides important insights about civilian healthcare use among veterans that are
not captured as well in VA studies. 
Methods
4. You say the sample "excluded participants who were institutionalized or
incapable of completing a 65-minute interview due to physical, language, or
cognitive impairment." Please explain briefly how such individuals were
identified in order to be excluded. 
5. In the procedure section, could you also indicate how long the survey took to
complete for respondents? There are many items in the variable description
section, so I'm curious. Do the authors think the length of the survey affected
their response rate?
6. Were respondents given any incentives for participation? 
7. Why was concussion history only assessed for concussions experienced
during military service? Why confine the history to only that period and not
examine the effects of lifetime concussion history? Justify in the manuscript. 
Results
8. I was wondering about interaction terms (e.g., sex and ACE score) as I read
the results, glad you addressed these and explained they didn't change the results.
9. The abstract implies service/treatment use would be an outcome measure, but
the inferential statistics only examine mental health disorders. Did you also
examine determinants of treatment use? I suggest you run these outcomes using
regressions as well, since your discussion and conclusions discuss how services
need to recognize gender differences given differences in mental health
outcomes. 
Discussion
10. You state, "Second, we only were able to successfully recruit 85 female
veterans" but did not explore how this may affect the results you present. Please
elaborate on the effects this may have on your findings. 
11. Have you considered another limitation may be not assessing LGBTQ
identities among your respondents? LGBTQ people are at higher risk for high
ACEs, and other predictors in your model and your outcomes. Perhaps
something to add to your limitations and suggest as an area of future research. 
12. I recommend, per comment #9, you also discuss the implications of gender
differences in service/treatment use and how your findings from that analysis can
shape non-VA health system care for women veterans. 
Conclusions
13. "…as all veterans deserve the best services possible." This is a value
judgement statement that I suggest removing. One could argue all groups deserve
the best care possible. 
14. The last sentence feels out of place and the conclusion ends abruptly. I
suggest re-writing and ending on a note that better captures the importance of the
paper for broader research on gender, veterans, and mental health. 
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the
authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Yes
Are you able to assess any statistics in the manuscript or would you
recommend an additional statistical review?
If an additional statistical review is recommended, please specify what aspects
require further assessment in your comments to the editors.
I recommend additional statistical review
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
Declaration of competing interests
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