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Women, Mental Health, and the Military

Chapter 44

women, mental health, and the 

military

DEBORAH CROWLEY, MD*; TRISHA BENDER, MD†; ASHLEY CHATIGNY, DO‡; TINA TRUDEL, PhD§; and

ELSPETH CAMERON RITCHIE, MD, MPH¥

INTRODUCTION

PSYCHOSOCIAL STRESSORS IN MILITARY SERVICE

Physical Fitness

Job Assignment

Location and Social Support

Deployments

Pregnancy

MENTAL HEALTH DISORDERS IN WOMEN

Schizophrenia

Depression

Bipolar Disorder

Anxiety Disorders

TRAUMATIC BRAIN INJURY IN WOMEN

Background

Traumatic Brain Injury, Gender, and Outcome

Psychological Sequelae of Traumatic Brain Injury in Women

Family and Vocational Issues for Women Following Traumatic Brain Injury

SUMMARY

*Captain, Medical Corps, US Army; Child and Adolescent Psychiatry Fellow, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett White 

Road, Honolulu, Hawaii 96859

†

Major, Medical Corps, US Army; Division Psychiatrist, 25th Infantry Division Headquarters, Building 580, DIVSURG CELL, Schofield Barracks, 

Hawaii 95857-6000; formerly, Child and Adolescent Fellow, Tripler Army Medical Center, Honolulu, Hawaii 

‡

Captain, Medical Corps, US Army; Fellow, Department of Child and Adolescent Psychiatry, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, Hawaii 96859-5000

§

Site Director, Defense and Veterans Brain Injury Center at Virginia NeuroCare, 1101-B East High Street, Charlottesville, Virginia 22902; Assistant 

Clinical Professor of Psychiatry and Behavioral Neurobehavioral Sciences, University of Virginia Medical School, Charlottesville, Virginia 22902; 

formerly, Executive Director, Lakeview NeuroRehabilitation Center, Effingham Falls, New Hampshire 

¥

Colonel, US Army (Retired); formerly, Psychiatry Consultant to The Surgeon General, US Army, and Director, Behavioral Health Proponency, Office 

of The Surgeon General, Falls Church, Virginia; currently, Chief Clinical Officer, District of Columbia Department of Mental Health, 64 New York 

Avenue NE, 4th Floor, Washington, DC 20002
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Combat and Operational Behavioral Health

INTRODUCTION

Before the military operations in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation 

Iraqi Freedom [OIF]), reproductive and gynecological 

issues dominated the medical concerns of most women 

in uniform. What was important to female soldiers was 

how to juggle family and career, with the occasional 

deployment to Korea, Somalia, or Kosovo, for a period 

of 6 to 12 months. “How do I manage with a baby? 

How do I figure out breastfeeding when I go to the 

field? How do I keep clean when the porta potties are 

all stinky and I’m having my period in the field? How 

do I deal with that?” 

Since the terrorist attacks of September 11, 2001, the 

world for female soldiers has changed. Women still constitute about 15% of the military. In the US Army, women 

are not still assigned in technical combat units, such as 

infantry and artillery. However, they are definitely and 

clearly in combat. Women are military police and truck 

drivers, as well as involved in a wide range of other fields 

where they have to be prepared to defend themselves. In 

the other military services, they do have technically combat roles. Because there are no safe lines anymore and no 

rear areas, women are increasingly being wounded and 

killed, although clearly not as frequently as men. 

PSYCHOSOCIAL STRESSORS FOR WOMEN IN MILITARY SERVICE

It is no surprise that life in the military brings a 

unique set of psychosocial stressors to women who 

serve. A multitude of expectations need to be met to 

succeed in the military, including a high level of physical fitness, extended work hours, a far-reaching network of rules and regulations, and 24-hour availability 

for duty. Service members can also be deployed at short 

notice, for varying lengths of time, and to almost any 

continent around the globe. Many potential benefits to 

military service also exist, such as employment stability, financial incentives for higher education, a unique 

camaraderie, and family support. The following section addresses unique challenges that can affect female 

service members and can have a significant impact on 

their mental health.

Physical Fitness

All service members are expected to maintain physical fitness to perform their jobs. Although each service 

has its own particular standards of fitness, there are 

more similarities than differences. Physical aptitude is 

measured in an annual or semiannual formal fitness 

test that evaluates muscular endurance and aerobic 

capacity. 

Each service also has standards established for 

varying categories of height and weight of each member.1

 This is also based on age and gender. If service 

members exceed the maximum allowable weight, they 

must meet a standard body fat percentage. Soldiers, 

both male and female, will frequently use various 

methods to meet the weight standards. Some of these 

methods involve physician-approved diet and exercise 

regimens. However, various other methods are used, 

to include crash diets, extreme exercise regimens, 

and alternative approaches, such as body wraps and 

wearing sauna suits. In some cases, this can result in 

development of an eating disorder, which is addressed 

in more detail in other chapters. 

Physical fitness is an obvious requirement for successful military service, with different jobs requiring 

different levels of physical strength and endurance. 

Generally speaking, male soldiers are expected to 

run faster and have greater muscular strength than 

female soldiers. This is based on the physical differences in muscle mass and distribution between the 

sexes. However, male and female soldiers are often 

required to complete the same physical tasks. For example, soldiers on jump status are expected to bear a 

certain load when they exit an aircraft, and that load 

is the same whether the parachutist is male or female. 

During deployments, female soldiers are required to 

wear the same load of combat gear as male soldiers. 

Completing these tasks is generally more difficult for 

female soldiers than for male soldiers, again because 

of the differences in body composition, muscle mass, 

and average size of each gender. This often becomes an 

added stressor for female soldiers, expected to meet the 

same standards as their male counterparts, but beginning with a different physiological makeup. 

If service members exceed the maximum allowance 

for body fat percentage, they are enrolled in a weight 

control program, which can include monthly weighins, mandatory classes and meetings with a nutritionist, and a specialized physical fitness regimen. If they 

fail to meet the standards for the physical training test, 

they can be enrolled in specialized physical training 

regimens. For physical training failure, soldiers can 

be barred from favorable actions, which can prevent 

them from being promoted, going on leave, or receiving 

awards. Soldiers can also be administratively separated 

from the service if they consistently fail to meet physical fitness standards.2

However, compared to their civilian counterparts, 

female soldiers may actually have an advantage by being expected to be physically fit. Studies have shown 
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Women, Mental Health, and the Military

that regular exercise regimens decrease the incidence 

or severity of symptoms of depression and anxiety.3,4

Exercise can be a very valuable coping skill to deal with 

the other stresses that the military imposes, both in and 

of itself, as well as in its role in improving sleep.

Job Assignment

For enlisted service members, military job opportunities are often assigned based on a test score resulting 

from the Armed Services Vocational Aptitude Battery 

(ASVAB).5 Many enlistees enter the service with an 

idea of the type of job they would like to have, but there 

is no guarantee the service will offer them the specific 

job they desire. Many soldiers are offered a limited 

number of jobs, and it can be quite upsetting when it 

is not something they are interested in. This often sets 

the stage for how soldiers will either look forward to, 

or dread, the time for which they have committed to 

serve. This is in contrast to employment in the civilian world, where most people are able to turn down 

the job they do not want or simply interview with a 

different employer. 

These same job assignment constraints also apply 

to commissioned officers. Officer candidates are given 

the opportunity to submit a preference list for their 

branch assignment. These assignments, however, are 

first and foremost based on the needs of the military; 

officer preferences are secondary. It can be a significant 

long-term stressor for someone who, for example, 

wants to be an aviator but is instead assigned to the 

Quartermaster Corps. Female soldiers are restricted to 

the noncombat arms branches with a few exceptions—

such as aviation and field artillery. For some women 

this is frustrating because they believe that if they can 

meet the same physical and technical standards of the 

job as men, they should be given the opportunity to 

perform that job. For other women who do not desire 

these jobs, the restrictions are a relief because they, 

unlike their male counterparts, do not run the risk of 

being assigned to them.

Location and Social Support

The military is a culture in which its people are 

expected to adapt to change. This change appears 

in many different ways—living environment, daily 

routine, job assignments, command as well as peer 

composition, and structure. For some individuals, 

the change is welcomed, and for others the change is 

dreaded. For all, it poses a significant stressor.

Many people join the military as an opportunity 

to travel the world. Frequent moves are often experienced, whether desired or not. Soldiers can voice 

a preference in assignment location, but ultimately 

service members are distributed according to the needs 

of the military. For young enlisted service members, 

basic training is often the first time away from home 

for an extended period of time. This removes them 

from everything that is familiar to them—families, 

friends, homes, daily routines, jobs, and ways of life. 

They are limited in their contact with their main social support network, and placed in an environment 

where they are told how to dress, how to walk, how 

to behave, and what to value. Most of these soldiers 

are relatively young, without a firm idea of who they 

are or their plan for their lives. This is a stressful time 

for all service members, male or female.

The nature of the military requires soldiers to be 

mentally and physically strong, bold, and aggressive. 

Society has traditionally reserved these characteristics 

for men, but recently women in the military have assumed an increased presence in customarily male 

roles, both as a result of changes in the country’s social 

values and the needs of the military.6

 In these surroundings, young female soldiers away from home for 

the first time all too often succumb to the temptation to 

engage in unhealthy behavior to fit in and be viewed as 

part of the team. This is their attempt to develop a new 

social support network in this stressful environment, 

as well as to be accepted by male colleagues. 

Deployments

Deployments are another major source of change 

unique to military service. At short notice, soldiers 

can be taken from the daily routine they have been 

accustomed to and transported halfway around the 

world for months at a time. This usually includes 

time away from loved ones, although the military has 

greatly improved deployed soldiers’ opportunities to 

communicate with loved ones back home.

Deployments can also mean harsh field conditions 

or climates to which the soldier is not accustomed. 

These austere conditions have an impact on personal 

privacy on a daily basis. Most significantly, deployments can place soldiers in situations of unpredictable 

or even certain danger with a threat to their lives. Any 

field situation, whether a training exercise at their 

home station or a deployment abroad, poses significant 

difficulties in the area of personal hygiene for female 

soldiers, who have to be prepared to deal with daily 

hygiene associated with menstruation even while in 

the field. Facilities for changing and disposing of hygiene products are not always available in the field, 

and time availability to take care of hygiene is often 

an issue as well. In addition to menstruation, urination is another stressor for female soldiers. During a 

field exercise, this becomes a matter of both privacy 

and convenience. However, during a deployment it 
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Combat and Operational Behavioral Health

can be a significant safety issue as proper wear of 

protective gear and avoidance of hostile fire become 

considerations.7

Deployments have become more common and more 

frequent for military service members over the last few 

decades. Recent studies estimate that soldiers entering 

the service today will have an average of 14 deployments over a 20-year career.8

 These include both combat deployments and peacekeeping missions. Studies 

have shown that service members generally want the 

opportunity to do what they have been trained to do, 

and most will find meaning in serving on a deployment.9

 However, over time, the stressors of a deployment will begin to take their toll on the physical and 

mental well-being of soldiers.

Deployment length appears to be a factor in the 

development of mental health problems for service 

members. Several studies have indicated that the 

longer a deployment lasts, the more psychological 

stress soldiers will experience, which, in turn, leads to 

development of symptoms such as depressed mood, 

sleep disturbances, increase in anxiety, and impairment 

in concentration.10 Most of these studies, however, focused on male soldiers. A study done by Adler and colleagues demonstrated that this relationship between 

length of deployment and stress may not be true for 

female soldiers. This may be related to a physiologic 

difference in stress response between men and women, 

a topic that in itself needs further research.10

Pregnancy

Pregnancy is a major stressor to military and nonmilitary women alike. There are physical changes, potential health problems, hormonal variations, and the 

adjustment to becoming a mother. In accordance with 

service-specific regulations, pregnant service members 

are given a medical profile, excluding them from regular unit physical training.11 This makes them exempt 

from formal physical fitness testing during pregnancy 

and for 180 days after delivery of the baby. 

Restrictions are placed not only on physical fitness 

requirements, but also on duty hours and tasks. This 

is to prevent potential complications in the pregnancy, 

for which the rate is already higher for women in 

the military than for their civilian counterparts.12 For 

example, after the 28th week of pregnancy the Army 

limits female soldiers to 8 hours of work at one time 

and 40 hours of work in a week.12 There are also restrictions that prevent working in motor pool areas, 

rifle ranges, from heights, or on aircraft. This can have 

varying effects on service members, depending on 

their assigned job and unit. For instance, for a female 

military physician, although this will reduce work 

hours and prevent being on call overnight, otherwise 

there may be little change to the daily routine. For a 

mechanic, however, a temporary job reassignment 

may be needed. Not only would this require a service 

member to learn a new job and adjust to a new work 

schedule, but her work as a mechanic would still need 

to be done by someone else in the unit.

The scenario with the mechanic poses yet another 

stressor for pregnant service members—potential 

social conflicts with her unit mates. As service members can be overtasked and overworked at baseline, 

extra work left by a pregnant service member is rarely 

welcomed. This can lead to resentment of the pregnant 

soldier by the other soldiers in the unit. In some units, 

however, just the opposite can happen. In cohesive 

units, soldiers rally around teammates who are facing 

challenges, and the resulting support can be much 

greater than what is found in civilian workplaces. 

The combination of a pregnancy and a pending 

deployment presents unique challenges. Because 

pregnancy precludes female service members from 

deploying,12 there is sometimes a perception that the 

service member intentionally became pregnant to 

avoid deploying. Not only can this prevent deployment, but the military also offers administrative separation for enlisted members who become pregnant.13

This can be seen by other soldiers as an abandonment 

of duty and obligation, regardless of the true intent 

of the pregnancy.

After the baby arrives, if the pregnancy is without 

complications, the service member is allotted 6 weeks 

of maternity leave. After these 6 weeks, the service 

member is expected to return to regular duty hours 

with her assigned job, although she is still exempt from 

physical fitness testing for 180 days postpartum. If the 

delivery required a Caesarean section, she may have 

difficulties with sit-ups. Women may have additional 

challenges meeting the military’s weight standards 

following pregnancy, even when given this 180-day 

recovery period.14

The US Army Center for Health Promotion and 

Preventive Medicine has now developed and disseminated a pregnancy physical training program for 

female soldiers. The “long-range goal of this program 

is to reduce the impact of pregnancy on individual 

soldier fitness and unit readiness by mitigating losses 

from attrition and reduced fitness.”15 Service members 

also continue to be nondeployable for 6 months following delivery, after which time they are expected 

to deploy like any other service member. Soldiers can 

choose to waive this 6-month “bonding period” and 

deploy shortly after delivery.16

One psychiatrist related his experience of deploying with a unit that contained several female 

soldiers who had chosen to waive their option to 

remain behind during their allowed bonding pe-
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riod.17 These female soldiers cited various reasons 

for their decisions, including not wanting to let 

their fellow soldiers down and wanting to perform 

the jobs they were trained to do. However, once 

deployed these women had significant problems, 

both mentally and physically. They experienced 

the expected emotional issues associated with being separated from their newborns. Physically they 

had not yet recovered from 9 months of pregnancy 

and subsequent childbirth. Many of these soldiers 

developed depression, and for some this led to 

suicidality. Not only did this scenario have a significant impact on the individual soldiers, but in 

turn it became an additional stress to their units in 

the deployed environment.17

This section addressed some of the psychosocial 

stressors unique to women in the military; however, it 

is not comprehensive. Some female service members 

are readily able to adapt and cope with these stressors, 

but for others they can lead to development of a mental 

illness. The rest of this chapter will address specific 

diagnoses in further detail.

MENTAL HEALTH disorders IN WOMEN

Although women are affected by the same major 

mental illnesses as men, there have been key differences noted in studies and a review of the literature 

of women’s mental health. These differences, such as 

history of presentation and course of illness, have an 

important impact on diagnostic and treatment considerations for the female patient. Furthermore, pregnancy, breastfeeding, perimenopause, and menopause 

can complicate mental well-being. This section will 

first consider each major mental illness separately.

Schizophrenia

Even though the ratio does not differ between genders, the onset of the disorder occurs later in women 

than in men (20–29 vs 15–24). A small percentage of 

women have their first psychotic episode in their 

forties.18 Women are more likely to have a good premorbid functioning history prior to their illness and 

during the course of their illness, display more positive 

symptoms with affective signs, and experience fewer 

negative symptoms than men.

Treatment of schizophrenia in the female patient 

does not differ from the standard practice guidelines, 

but a few gender-specific situations do occur. Some 

antipsychotic medications (risperidone, haloperidol) 

can induce hyperprolactinemia (normal prolactin 

5–25 ng/ml), thus causing menstrual irregularities 

or amenorrhea (prolactin over 60 ng/ml). In cases in 

which the medication cannot be switched or lowered, 

the hyperprolactinemia could be managed by adding 

the dopamine agonist bromocriptine (2.5–7.5 mg twice 

daily) or cabergoline (0.5 mg/week).19 Alternatively, 

oral contraceptives could be used to restore the menstrual regularity disrupted by the hyperprolactinemia, 

in addition to providing contraception.

Women with schizophrenia are at high risk for 

unplanned pregnancy because of ineffective use of 

contraception and high rates of sexual assault. Prevention should include counseling about preferred 

choice of birth control, sex education, and psychosocial 

support. Patients with schizophrenia who do become 

pregnant require frequent monitoring. Reemergence 

of psychotic symptoms can lead to failure to obtain 

prenatal care, paranoid delusions about the medical 

team that prevent cooperation, poor self-care, and 

adverse pregnancy outcomes (ie, low birthweight, low 

Apgar scores, prematurity). These factors, in addition 

to previous functioning, must be considered when 

deciding treatment during pregnancy.

There are limited data on the effects of antipsychotic medications on the fetus. Some data showed 

no increased risk of congenital malformation with 

high-potency agents (haloperidol and trifluoperazine), although low-potency phenothiazines appear 

to have a higher incidence of nonspecific congenital 

anomalies and neonatal jaundice.20 The newer atypical antipsychotics have only a few case reports. These 

do not indicate adverse effects; however, with their 

small numbers, these reports give the clinician little 

guidance. With either the decision to treat with medication or to watch symptoms, the patient will need 

close follow-up and involvement of any psychosocial 

supports that the patient has enlisted.

Depression

The prevalence of unipolar depression for women 

is statistically higher (10%–25%) compared to men 

(12%).21 Dysthymia is twice as prevalent in women as 

in men.22 Similarly, seasonal affective disorder is also 

more prevalent in women than men.23 Although the 

symptoms of depression do not differ significantly 

between the sexes, women are at risk for depressive 

episodes during reproductive transitions such as 

premenstruation, pregnancy, postpartum, periomenopause, and menopause.

Premenstrual dysphoric disorder (PMDD) is listed 

as a mood disorder not otherwise specified in the 

fourth edition of the Diagnostic and Statistical Manual

(DSM-IV-TR) of the American Psychiatric Association, which describes the severe spectrum of recurrent 
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physical and emotional symptoms associated with 

the late luteal phase of the menstrual cycle, which 

resolve with the onset of menstruation. The physical 

symptoms include headaches, cramping, breast tenderness, and bloating, while the emotional symptoms 

include depression, irritability, anxiety, and insomnia. 

After ruling out other causes of symptoms (including other medical and psychiatric disorders such as 

unipolar depression, dysthymia, and anxiety), PMDD 

can be monitored with daily symptom charting over 

a 2-month period. Treatment is based on the severity 

of symptoms and ranges from nonpharmcological 

approaches, such as sleep hygiene, relaxation therapy, 

and cognitive-behavioral therapy, to the addition of 

selective serotonin reuptake inhibitors (SSRIs) for the 

more severe cases.

Maternal depression during pregnancy creates risks 

for both the woman and her children, such as alcohol 

abuse, poor nutrition, failure to obtain adequate prenatal care, and suicidal behaviors. Obstetrical complications have also been studied and have shown increased 

risk for slow fetal growth,24 small infant head circumference,25 and increased risk of preterm delivery.26

The US Food and Drug Administration (FDA) uses 

a pregnancy rating system27 to guide clinicians on 

potential safety of a medication during pregnancy or 

lactation (Exhibit 44-1). However, the rating system 

does not always reflect the available data. Also, there 

can be some lag time before new data are incorporated 

into the system. It is important to note that to date, 

in the absence of controlled trials, the FDA has not 

approved any medications for use during pregnancy 

or lactation. Thus, it is important to obtain informed 

consent with each patient about the risk-to-benefit ratio 

when using a psychotropic. 

When medications are used in pregnancy, the 

EXHIBIT 44-1

US FOOD AND DRUG ADMINISTRATION CATEGORIES and labeling requirements

FOR DRUG USE IN PREGNANCY

Pregnancy Category:

 A Studies in pregnant women have not shown that (name of drug) increases the risk of fetal abnormalities if 

administered during the first (second, third, or all) trimester(s) of pregnancy. If this drug is used during pregnancy, the possibility of fetal harm appears remote. Because studies cannot rule out the possibility of harm, 

however, (name of drug) should be used during pregnancy only if clearly needed.

B Reproduction studies have been performed in (kind(s) of animal(s)) at doses up to (x) times the human dose 

and have revealed no evidence of impaired fertility or harm to the fetus due to (name of drug). There are, 

however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly 

needed.

C (Name of drug) has been shown to be teratogenic (or to have an embryocidal effect or other adverse effect) in 

(name(s) of species) when given in doses (x) times the human dose. There are no adequate and well-controlled 

studies in pregnant women. (Name of drug) should be used during pregnancy only if the potential benefit 

justifies the potential risk to the fetus.

 D (Name of drug) can cause fetal harm when administered to a pregnant woman. (Describe the human data and 

any pertinent animal data.) If this drug is used during pregnancy, or if the patient becomes pregnant while 

taking this drug, the patient should be apprised of the potential hazard to a fetus.

X (Name of drug) may (can) cause fetal harm when administered to a pregnant woman. (Describe the human data 

and any pertinent animal data.) (Name of drug) is contraindicated in women who are or may become pregnant. 

If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient 

should be apprised of the potential hazard to a fetus.

Data source: Code of Federal Regulations,Title 21, Volume 4, Revised as of April 1, 2008 (21CFR201.57). Available at: https://www.

accessdata.fda.gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch.cfm?fr=201.57. Accessed September 2, 2009.
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Women, Mental Health, and the Military

minimal effective dose should be administered. That 

is, the dose that effectively treats a patient’s symptoms without unduly exposing the fetus to higher 

than necessary doses. To date, the SSRIs, in particular 

fluoxetine, have the most extensive published data 

about their use during pregnancy. One study on the 

long-term neurobehavioral effects of SSRIs during 

pregnancy compared children exposed to fluoxetine, 

or a tricyclic antidepressant, or no antidepressant. No 

significant differences between the three groups were 

noted.28 All SSRIs have FDA risk category of “C,” 

with the exception of paroxetine, which has a risk 

category of “D” and is not recommended for use during pregnancy. In the United States, physicians have 

increasingly prescribed bupropion during pregnancy 

to treat depression, apparently as a consequence of its 

FDA “B” risk category. However, there are currently 

no published data regarding its safety or tolerability 

during gestation.

The postpartum period can be a particularly vulnerable period for a woman, with up to 85% of women 

experiencing postpartum “blues” within the first 2 

weeks after giving birth. This condition usually remits 

spontaneously, and thus treatment is not required. 

However, psychoeducation of physician and patients 

to distinguish postpartum blues from a more serious 

condition, postpartum depression, is warranted. The 

prevalence of postpartum depression is about 10%. 

Any previous history of depression significantly increases the woman’s risk dramatically. A history of 

PMDD prior to conception increases her risk for developing postpartum depression to 24%. An episode 

of depression endured during pregnancy increases the 

risk of postpartum depression to 35%. Any woman 

with a prior history of postpartum depression has a 

50% to 60% risk of developing postpartum depression 

during subsequent pregnancies.29 Treatment is multimodal and includes psychoeducation, individual and 

group psychotherapy, support (community resources), 

and pharmacotherapy. Breastfeeding should be discussed thoroughly as all psychotropic medications 

pass through breast milk and there are limited data 

establishing the effects on the infant. For the patient 

whose depression is complicated by psychosis or suicidality, hospitalization is generally required until the 

patient is no longer dangerous to self or others. Postpartum psychosis is considered an acute emergency 

and reason for acute admission, as it carries a risk of 

infanticide (1/1,000) if left untreated, in addition to the 

risks to the mother associated with psychosis.

Bipolar Disorder

 Bipolar disorder occurs in 1% of the population and 

is equally prevalent in men and women. Women tend 

to experience more depressive and mixed episodes 

than men, with fewer manic episodes. This may lead 

to diagnosis of unipolar depression and treatment with 

antidepressants, which then exacerbates the condition 

and results in rapid cycling—a condition seen more 

often in women than in men.30 Another precipitation 

of rapid cycling is thyroid dysfunction, which can be 

caused by lithium-induced hypothyroidism. Women 

are at greater risk for thyroid dysfunction than men, 

thus levels of thyroid stimulating hormone should 

be checked every 6 months for any woman receiving 

lithium.

Management of bipolar disorder can be particularly 

challenging during the perinatal period because the 

current first-line agents either have known teratogenicities, are associated with congenital malformations, or have little data to support their safety during pregnancy or lactation. In particular, lithium has 

been demonstrated to increase the risk for Ebstein’s 

anomaly (also called Ebstein’s malformation, in which 

the tricuspid valve is abnormally formed) from 1 in 

20,000 to 1 in 1,000 when the fetus is exposed during 

organogenesis.31 Exposure later in gestation can lead to 

fetal or neonatal cardiac arrhythmias, fetal hypoglycemia, nephrogenic diabetes insipidus, polyhydramnios, 

or premature delivery.32,33 The American Academy of 

Pediatrics discourages the use of lithium during lactation. This recommendation is based on a study that 

revealed that infant serum levels are double maternal 

serum levels postbreastfeeding. Lithium use during 

lactation is also correlated with adverse events such 

as lethargy, hypotonia, hypothermia, and electrocardiogram changes.34

Prenatal exposure to valproate is associated with 

neural tube defects and craniofacial, cardiovascular, 

and limb anomalies.35 A metaanalysis revealed the risk 

for neural tube defect during valproate exposure to be 

3.8%—38 times greater than prevalence in the general 

population.36 There is a paucity of data regarding the 

use of the atypical antipsychotics during pregnancy 

and lactaction. 

Anxiety Disorders

Overall, anxiety disorders are more prevalent in 

women than in men (with the exception of obsessivecompulsive disorder, which has equal prevalence). 

Compared to men, women are twice as likely to suffer 

from posttraumatic stress disorder (PTSD), three times 

as likely to experience panic disorder with agoraphobia, and four times as likely to have social phobia.37,38

Although other comorbid psychiatric disorders occur in 91% of patients with panic disorder, and 84% of 

patients with panic disorder and agoraphobia, panic 

disorder with agoraphobia is more common in alco-
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holic women than alcoholic men.39 The treatment for 

panic disorder does not differ between the genders, 

with the most effective treatments consisting of cognitive behavioral-therapy and pharmacotherapy. 

Comprehensive evaluation to rule out disorders 

that mimic anxiety, to include thyroid disorders, lupus, iron deficiency anemia, cardiovascular disease, 

and periomenopause, should be included in the work 

up. Other causes of anxiety—such as alcohol use, 

nicotine, caffeine, nonsteroidal decongestants, herbal 

supplements, and appetite suppressants—should also 

be ruled out.

TRAUMATIC BRAIN INJURY IN WOMEN

Background

Traumatic brain injury (TBI) is one of the most 

complex conditions of high risk to military personnel, 

affecting physical, cognitive, and behavioral health. 

Rates of TBI in the general population and military 

are high, making this condition a major public and 

military health problem. In the current war on terror, 

brain injury has become a predominant injury for 

military men and women in a wide variety of roles. 

The focus on TBI has increased with the occurrence of 

such injuries in OIF and OEF. With regard to OIF, the 

Office of The Surgeon General of the Army notes that 

64% of wounded-in-action injuries have occurred as 

a result of blast from improvised explosive devices, 

rocket-propelled grenades, land mines, and mortar or 

artillery shells.40 Improvements in helmet design and 

body armor have resulted in reductions in penetrating 

injuries, including penetrating head trauma. As a direct 

result of the improved survivability of blast injuries, 

closed-head trauma has become the signature injury 

of these military operations. 

The detailed review of military TBI—from moment 

of injury through medical and rehabilitation setting 

and finally to vocational and family outcome—has 

been addressed in a prior volume of the Textbooks of 

Military Medicine.

 41 Therefore, this section will only focus on familiarizing the reader with research findings 

regarding gender differences and their implications for 

women. Even though male TBI outnumbers female TBI 

approximately 2:1 in the general population, and men 

in the military population far outnumber women, the 

rates of female TBI and female service members have 

both increased over the past decade. Understanding 

the implication of female gender in all aspects of TBI 

has developed during this time, although it is still in 

its infancy.

Traumatic Brain Injury, Gender, and Outcome

The analysis of gender as a variable in neurotrauma 

is a fairly recent phenomenon, with discrepant results 

across a number of studies. Animal models suggest 

positive effects of hormone treatment (progesterone, 

estrogen) on outcome, and potential differential risk/

benefit for women who are either pre- or postmenopausal. Progesterone modulates gamma-amino butyric 

acid and inhibits apoptosis, gliosis, and production of 

inflammatory agents, thereby reducing brain edema. 

Estrogen is known as a powerful antioxidant with 

vasoprotective action. However, in animal models, 

although exogenous administration of estrogen was 

beneficial to males, administration to females was 

detrimental, and increased rates of injury-related 

mortality.42–44

Hormonal issues may also play a significant role in 

mild TBI diagnosis among periomenopausal, menopausal, and postmenopausal women, due to symptom overlap. For example, in examining population 

base rates, in excess of 20% of these women report 

concentration difficulties, sleep disturbance, anxiety, 

depression, and irritability, all symptoms common to 

mild TBI. In excess of 30% of these women also report 

fatigue and nervousness.45

A metaanalysis on gender differences in TBI outcome identified only nine studies where data were 

reported based on gender. In analyzing these available 

studies, women were observed to have worse outcome 

on 85% (17 of 20) of the variables discussed.46 Other 

individual studies, often with relatively small samples 

of women, present conflicting results wherein women 

demonstrated greater response to coma stimulation,47

gains in postacute rehabilitation,48 maintenance of 

cognitive level relative to age norms,49 and lower risk 

for dementia.50

Among those with moderate to severe TBI, female 

survivors were noted to have a 1.28 times higher mortality rate and a 1.57 times higher poor-outcome rate 

than male survivors.51 Research regarding the much 

more common concussion/mild spectrum of TBI 

demonstrates that female gender is associated with a 

greater likelihood of subjective cognitive complaints.52

Women were also noted to have significantly higher 

rates of postconcussive syndrome at 1-month postinjury, with continued trends in this direction at 3 and 6 

months postinjury.53 Women sustaining sports-related 

concussions demonstrated significantly greater decline 

in simple and complex reaction time and reported 

more postconcussion symptoms than male peers. In 

this sports-related concussion study, female subjects 

were cognitively impaired roughly 1.7 times more 

often than comparison male subjects. They also expe-
711

Women, Mental Health, and the Military

rienced more subjective and objective adverse effects 

from concussion, even with adjusting for helmet use 

(such as comparison male football players).54 Thus, 

especially in mild TBI, it is critical that women have 

thorough evaluation and follow-up to reduce risk of 

complications, avoid repeat injury, and ensure optimal 

recovery.

Psychological Sequelae of Traumatic Brain Injury 

in Women

Results related to gender, overall outcome, and 

quality of life are also mixed, because few of the many 

TBI studies present results by gender. A recent larger 

sample study contradicts early findings of higher 

perceived quality of life among females post-TBI.55

A number of studies specifically examining depression post-TBI demonstrate a significant association 

between female gender and post-TBI depression.56–58

The finding of higher rates of post-TBI depression 

among women is not unexpected given the higher 

rates of depression among them in the general population. Thus, detailed depression screening is strongly 

recommended.

TBI with concomitant PTSD is a particular concern 

in military settings. When experiencing the same 

trauma, women have higher rates of PTSD than men 

in the general population. This finding appears to hold 

true for PTSD post-TBI. A number of studies report that 

women manifest higher rates of post-TBI PTSD.59–61

One study noted that symptoms increased over time, 

and that both the severity of the TBI and memory for 

the event were not associated with the PTSD diagnosis, 

which involved predominant intrusion and avoidance 

symptoms.62 Complicating factors associated with 

PTSD and female TBI survivors include a premorbid 

history of sexual trauma and abuse, which occurs at 

a significantly higher rate for women in population 

studies. 

In some instances, the experience of TBI is noted 

to trigger reemergence of intrusive recollections and 

symptoms associated with abuse, at times after years 

of nonoccurrence. This PTSD-related complication can 

disrupt the rehabilitation process through flashbacks, 

behavioral and affective disturbance, nightmares, and 

hypervigilance. Issues related to prior sexual trauma 

and abuse should be proactively addressed in the history and treatment planning process.62 Also related to 

post-TBI psychological status and PTSD risk is the high 

rate of TBI from domestic violence, wherein women 

are more frequently the victims. Studies of battered 

women indicate extremely high frequency of blows to 

the head (92%) and loss of consciousness (40%), with a 

significant correlation between frequency of blows to 

the head and severity of cognitive symptoms.63 Along 

with blows to the head, battered women also may 

experience anoxic injuries from choking, and are very 

likely to suffer from multiple brain injuries. Women 

sustaining brain injuries in the context of domestic 

violence often present both cognitive impairment as 

well as psychological symptoms, including generalized distress, depression, anhedonia, worry, anxious 

arousal, and PTSD.64 Screening for TBI following domestic violence, and for domestic violence risk among 

those women presenting with TBI, is advised.

Family and Vocational Issues for Women Following Traumatic Brain Injury

Examination of the burden of TBI on family members indicates spouses and primary caregivers typically experience the most stress. Divorce and family 

dysfunction are extremely common occurrences postTBI. Research indicates that male caregivers of female 

relatives with TBI displayed more distress on clinical 

inventories than any other gender combination. Time 

since injury and days in coma (a measure of severity of 

injury) did not affect family caregiver distress ratings.65

Thus, family treatment and support should be initiated 

as early and as intensely as possible, especially in those 

circumstances where the woman with TBI will likely be 

dependent to some degree on a family caregiver. 

Women with TBI additionally may have difficulty 

functioning in their spousal role, as the injury may 

affect satisfaction with gender role, body image, selfesteem, and sexuality. Gender-role satisfaction relates 

to a woman’s ability to engage in preinjury activities 

that defined and supported her sense of femininity and 

womanhood. It is particularly beneficial for women to 

reconnect with rites of passage and developmental lifestage transitions, such as partnership with another or 

parenting children, or both, as a means of expressing 

the ability to participate.66 In moderate to severe TBI, 

rehabilitation may be extended and involve stays in 

various settings, all of which may separate the female 

service member from military, family, and gender 

roles—an experience associated with diminished 

personal satisfaction and self-esteem. Nontraditional 

rehabilitation and therapeutic activities may be needed 

to enhance ability to function in the multitasking role 

as mother for those service women with children at 

home and parenting responsibilities.

Body-image concerns and sexual dysfunction also 

adversely affect self-esteem and may contribute to depression. Following TBI, body image difficulties may 

influence feelings of attractiveness and comfort being 

seen by a partner; physical difficulties may impact 

sexuality through body positioning, sensation, and 

movement; and physiological problems may reduce 

energy for sex, sex drive, ability to initiate sex, and 
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Combat and Operational Behavioral Health

ability to achieve orgasm. Predictors of women’s sexual 

dysfunction post-TBI include degree of depression and 

evidence of endocrine disorders. Significant problems 

reported by women with TBI include difficulties with 

sexual arousal; pain with sexual activity; decreased 

ability to masturbate; diminished vaginal lubrication; 

and altered, delayed, or lack of orgasm.67 Rehabilitation and psychotherapy professionals must be able 

and willing to engage in frank discussion of sexuality 

post-TBI. They must also have some familiarity with 

treatment approaches and resources, because problems 

in this area are associated with depression, loss of selfesteem, and increased family strain.

Successful recovery from TBI results in return to 

work for military personnel with TBI. Some soldiers 

are even able to return to active duty. Others may no 

longer be able to serve in such roles and may require 

vocational rehabilitation to achieve community 

reintegration. Studies have demonstrated worse vocational outcome for women post-TBI than for men. 

At times data suggesting good outcome for women 

are deceiving, in that successful vocational outcomes 

have included the category of “homemaker,” often 

with minimal definition or analysis of tasks and 

function. Significantly fewer women return to work 

full-time post-TBI.68 A review of state vocational 

rehabilitation services was conducted comparing 

men and women with similar injuries, neuropsychological test results, and demographics. Women 

were noted to have vocational rehabilitation services 

terminated after being accepted, but before successfully initiating active services, almost 50% more often 

than men; women received vocational rehabilitation 

maintenance services half as often as men; and only 

4.4% of women (vs 23.6% of men) were employed 

successfully through vocational rehabilitation.69 The 

return-to-work outlook is challenging for anyone 

post-TBI. However, the vocational outlook for women 

is particularly disconcerting, and may necessitate 

extra efforts on the part of vocational rehabilitation 

counselors and advocates.

Thus, the sequelae of TBI are complex and may 

involve rehabilitation of cognitive, physical, and behavioral impairments. Women with TBI are especially 

vulnerable to cognitive complaints and problems such 

as depression and PTSD. It may be difficult for women 

post-TBI to return to family and vocational roles. The 

clinician is advised to be aware of, and proactive 

regarding, women’s unique issues post-TBI, because 

early intervention may improve outcome and reduce 

risks of long-term disability and the emergence of 

comorbidities.

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This chapter has discussed the unique and challenging situation that women face in today’s military. 

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