Reviewer’s report
Title: 
Risk and Protective Factors Associated Mental Health among Female
Military Veterans: Results from the Veterans’ Health Study
Version: 
0 
Date: 
04 May 2020
Reviewer's report:
This manuscript by Adams and colleagues uses a large sample of veterans who
receive at least some of their healthcare from a non-VA, non-military healthcare
institution to compare women and men with regards to lifetime and current
incidence of PTSD, depression, and suicidal ideation. Overall the paper is well
written and the non-VA nature of the sample is a major strength. There are just a
few issues that I would like to see addressed to strengthen the work and to
optimize its utility to the field and to policy makers.
More major issues
1. The discussion is very thin and would benefit from significantly greater
description and interpretation of the findings. In particular, the following issues
need to be unpacked:
a. What do the authors make of the lack of between gender differences in the
multivariate analyses when indicators of current PTSD, depression, and suicidal
ideation were used as opposed to the findings from models involving the lifetime
indicators? 
i. Is it a power issue or is there really something to the discrepancy between the
current and lifetime patterns such that when the covariates are included, there
aren't that many current differences between women and men? 
ii. I realize it's likely not possible to tell for certain, but some discussion of this is
warranted if for no other reason than to have the first sentence of the conclusion
("….our findings support the case for more gender-informed planning, given the
projected increase in female veterans in both the US and other industrial
countries.") make sense (i.e., if there aren't apparent current gender differences
then why should institutions go to the trouble of changing things to address the
small minority of women?).
b. It would also be useful for the authors to at least briefly address the patterning
across the different propensity score analyses such that for all the outcomes, the
models involving the 1:1 matches look to be indicating less strong associations
than the ones involving either 1:3 or 1:5 matches. Is this a power issue or is it
that when only the optimally matches of man to woman (1:1) are included the
differences are not as pronounced - still significant (for lifetime at least), but less
pronounced?
Less Major Issues 
2. A lot of analyses were conducted but there is no mention of whether (or how)
was Type I error controlled.
3. The choice of 40 drinks per month as the indicator for heavy drinking is
problematic for both women and men and surely it should not be the same for
both sexes, regardless. If there is any way to calibrate this so that it at least
conforms grossly to the CDC and NIAAA guidelines for women (max 7 drinks
per week so over 28 drinks per month would be heavy) and for men (max 14
drinks per week so over 56 drinks per month would be heavy), that would be
helpful.
4. The requirement that suicidal ideation persisted for two or more weeks to be
counted as such seems extreme and is likely missing a lot of SI that could still be
clinically meaningful and so I suggest noting this as a limitation.
5. The lack of a specific indicator of military sexual trauma is also a study
limitation.
6. ADHD history is first introduced in the data analysis section and some
indication of how this was measured should be included earlier.
7. I do not understand what this sentence in the conclusion section is getting at:
"Studies of non-VA healthcare delivery to veterans will be important to develop
public-private partnerships, which are especially important so medical and
mental health facilities for veterans can better address gender differences…"
There's a lot packed in here that is presented too telegraphically to be readily
understood.
Very minor things
8. There is a stray "the" preceding 95% in the Abstract (line 41).
9. In the Discussion (pg. 11, line 41) "many" should be "may"
Please note that I am pushing on the issues I think need to be fleshed out in the
discussion (1.a and 1.b above) because I think the investigators are likely
uncovering important gender differences that need to be taken into consideration
both for treatment planning and healthcare delivery purposes, but without some
way of understanding what might be going on with the very different pattern of
results across the current and lifetime models, in particular, it would be easy for
policy makers to disregard the findings.
.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
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.
No
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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