**Transcript of Cyberseminar**

**Spotlight on Womens Health**

**Systematic Review of Women Veterans’ Unique Mental Health Needs**

**Presenters: Jennifer Strauss, PhD, MS,  and Natara Garovoy, PhD**

**October 10, 2012**

**Systematic Review of Women Veterans’ Unique Mental Health Needs**

**October 10, 2012**

Moderator:We are almost at the top of the hour so I would like to introduce our speakers for today. Speaking first, we have Dr. Jennifer Strauss. She is the Women’s Mental Health Program Manager for Mental Health Services at V.A. Central office. Joining her is Dr. Natara Garovoy, and she is the program director for Women’s Prevention Outreach and Education Center at VA/Palo Alto Healthcare System. We are very grateful for our presenters today. Dr. Strauss, are you ready for me to turn it over to you?

Jennifer Strauss:I am indeed.

Moderator:Ok. Just click, show my screen when you are ready and we will get going. Perfect, thank you.

Jennifer Strauss:Ok. I think everyone should see my slides at this point. 

Moderator:Correct. I will just ask you to speak up a little bit.

Jennifer Strauss:Of course, happy to. Ok, so first of all, I would just like to place a vote for mushrooms and extra cheese in terms of pizza toppings. That was something that, it was our first empirical question I think of the morning. Today, we are going to be discussing a systematic review of women veterans’ unique mental health needs. 

Thank you, first of all for inviting us to share this topic. I – if all goes well, I think we will, I think and I hope that we will learn more from the audience, or at least as much from the audience as we hope to convey to them. We are looking forward to a lively dialogue, and lots of learning, and questions.

To get us started, I would like to put the acknowledgements first, because sometimes when time runs short, we tend to rush through this piece. This was definitely a case of it takes a village. This project was born out of, and we will talk more about this in a moment, but it was born out of a partnership with – between the Department of Defense and the VA within the integrated mental health strategy. In terms of our investigators, this has been really truly taking a village. 

Myself, Dr. Garovoy, and Dr. Susan McCutcheon, who is our supervisor all work within the women’s mental health section of VACO. We partnered in this particular case with a few other key groups. One, we want to give a shout out to the VISN 6 MIRECC. That MIRECC has a focus on OEF/OIF mental health, and I guess OND post-deployment mental health; and particular interest in women veterans research in that group. John Fairbank, who leads that effort, was generous enough to allow investigators with an interest in this topic to volunteer time to help us with this pretty large undertaking. You will see Jennifer Runnals, Monica Mann-Wrobel, Allison Robbins, Alyssa Ventimiglia. All and the workgroup there, all were folks within VISN 6 MIRECC who did significant work on this effort. 

We also were able to partner with Paul Shekelle and Isomi Miake-Lye who are with the West, the West L.A. VA Evidence Synthesis Program. That group actually had conducted prior evidence reviews of this topic and were really generous in sharing their methodological expertise; and helping us to run our database search in a way that matched, actually mirrored,  some of the methods that were used in prior reviews. We were able to kind of pick off where – pick up where prior reviews left off. Then, of course, Jenny Hyun, Kate Iverson, Jan Kemp, Linda Lipson, and Dawn Vogt were all key content matter experts that reviewed prior versions of this work. A rousing thank you to everybody who helped so much to pull this together. 

With regard to our agenda, Natara and I are going to – are going to volley a little bit on this. She is actually going to get things started by providing an overview of women veterans mental health. I will chime in and give a little bit of background on this Department of Defense and VA collaboration, the integrated mental health strategic action. Ours in particular, which relates to gender differences. We will talk about the current evidence review, look at next steps and highlight some relatively new resources that we think are available to move this work forward in the future. 

I think with that I am going to hand the baton to Natara, but I will be... I think I am going to be advancing slides. Just Natara, tell me when you want the next slide up, and I will do it.

Natara Garovoy:Will do, thank you, Jennifer. Well, the population of women veterans that we are discussing today really deserves our attention, not only because of their rapid growth, but also because of their continuing minority status. As we will see today, the group faces unique challenges. It is important that every service really be available to them. This includes the full continuum of mental health services. 

The full continuum spans from outpatient services, that can be screening, assessment. It can be med evals, individual group therapy. It includes specialty services for conditions like PTSD or substance use disorders, as well as all the evidence-based therapies, and of course, inpatient and residential treatment options. Those can be both mixed gender or women only. Next slide, please.

With regards to single gender, this is a mixed gender program. The VA does recognize that veterans will benefit from treatment in an environment where all of the veterans are of one gender. Some of the issues that this may uniquely and specifically address are ones of concerns of safety. That can be for instance particularly important in a case where there is a history of interpersonal trauma. It may also improve veterans’ ability to disclose and address gender specific concerns. It may also enhance treatment engagement and social support. In particular, it may serve to foster a unique sense of community event [sic] when we have a single gender environment can, particularly when the group is in a minority status as I mentioned earlier. 

The VA also recognizes that mixed gender programs also have advantages. They may help veterans challenge assumptions and confront fears about the opposite sex. In this way, may actually provide an emotionally corrective experience that only a mixed-gender program can provide. Also, promotes an efficient use of resources. By accepting both men and women, this helps prevent admissions slots or the appointments of any kind from going unused. Because the pool of people who are in line to use them broadens. Women can and should have access to all services and not be limited to women only treatment settings.

Given these considerations, the VA does not promote one model over the other. But really, it is the needs of the specific veteran that dictate which model is most clinically appropriate. I believe that the situation of interpersonal trauma really can provide a very good example of the importance of this approach. We know that when a woman veteran for instance has experienced severe interpersonal trauma. Perhaps, the case of MST may be a particular example of this where her perpetrator was a man. She may feel very uncomfortable in situations that are predominately male. 

The question is at what stage is she ready to start integrating into a mixed gender environment versus maybe starting in a single gender environment. It may be that a women’s only program may be the best place for her to start. But then making mixed gender programs available to her as she becomes ready really promotes an understanding of why this meets the veterans’ [inaudible] might dictate which is most clinically appropriate at the given time. 

Next slide, please. We know that women veterans can receive services at all VA medical centers. We also know that some facilities have established formal outpatient mental health treatment teams specializing in working with women veterans and that these offerings do vary from facility to facility. They are typically based on the local demand. The population of women veterans that may be seeking services at that particular facility. As well as the resources that may be available to provide the women only environments and treatment settings. 

The VA also has residential inpatient programs to provide treatment to women only. Some of these residential inpatient programs also have separate tracks for men and women. The environment itself may not be specific to one gender. But there may be programming that is specific. Next slide, please. I am now going to shift here and talk about what we are seeing in terms of trends in our healthcare system. 

Next slide, please. Among OEF/OIF, and OND veterans in the VA. This is between the years 2002 and 2012. We see that there are over 50 percent of this sub-group is being diagnosed with disorders in a mental health spectrum. This includes PTSD, non-PTSD, anxiety, and depression. This example is that really all mental health disorders fall into this category. We also see that the numbers are high for physical health problems as well. I will just add one important note in terms of understanding this data, that these percentages are not mutually exclusive. 

Next slide, please. We also see that this subgroup is accessing VA care at unprecedented rates. The most common mental health disorder among this group is depression and PTSD. This is both among men and women. We also see that from the latest research shows in terms of gender differences that women may be just as resilient to the effects of combat stress as men in the year following return from deployment. 

Next slide, please. You are looking at the change in mental health services. I mean, in administration data suggests that women veterans are also increasingly accessing mental health services in addition to services overall. On this slide you can see that the breakdown across the continuum of care with women veterans accessing residential care programs. That increased 47.4 percent. Outpatient care increased 69.8 percent; a pretty significant increase there. It is with an overall increase of approximately 24 percent. This is between the years 2005 and 2010. 

Next slide, please. I am now going to pass the mic back to my colleague Jennifer Strauss who will start by addressing the next item in our agenda, which is Strategic Action Number 28.

Jennifer Strauss:Thank you. Some of you – my guess is many on the call are familiar with this collaboration. But just by way of background, I want to give some information about a really pivotal actual partnership between the Department of Defense and VA. This is borne out of a Mental Health Summit that was convened in 2009. That summit kind of recognized it was, I think, held because DoD and VA both recognized and identified the need for an integrated strategy for the provision of mental health care to military service members, and veterans, and their family members. Within this summit from that summit, the VA and DoD jointly identified 28 Strategic Actions focusing on establishing continuity between access of care, treatment settings, and transitions between the two departments. Then for each of these strategic actions a work group was assigned, each of which has representation from VA and DoD, clinicians, researchers, and policy experts relevant to the content matter of this specific Strategic Action.

Of the 28, last but definitely not least, Strategic Action Number 28 is focusing on gender differences. Dr. Susan McCutcheon is the VA lead on this effort. Natara, myself, and members of the VA’s MST support team are core members of this work group, the charge of which is to explore gender differences in delivery and effectiveness of prevention and mental health care for women; and for those both genders who experience military sexual trauma. To identify disparities, and specific needs, and opportunities for improving treatment and preventive services. 

When this work group was established and when the Strategic Action was kind of formally laid out through various planning within the two departments, our work group was given several key milestones to complete together. One of the very first of which was to conduct a systematic evidence review relative to this topic and to inform the work of the work group moving forward. 

We did not wake up one day and decide, gosh, I think we will conduct an evidence review. But it happened that there is a need for it. It dovetailed beautifully with this call through this partnership with – between VA and DoD to conduct an evidence review looking at women veterans’ mental health. That was the genesis for the project that we are going to be presenting today.

To get us started; so we are going to talk. The focus really is going to be on the evidence review that our team conducted recently in the past year. But, reporting that out of context does not make a lot of sense. There have been three really significant evidence reviews that were conducted prior to ours. We are going to begin by providing some broad overview of those past three systematic reviews. That will give some context to our findings and how we interpreted the literature more recent. 

What you are going to see is that over the past several decades there has been a tremendous amount of growth in research in women veterans. Lots of interest in the field and lots of amazing work being done. Prior reviews have focused predominately on – or, broadly, I guess on women’s health. As we review prior reviews because our focus is really on women’s mental health. Just in the interest of time we are going to provide a summary of key findings. But really as it relates to women’s mental health research. 

We may be preaching to the choir here. But, there is the question of why look at gender?  I mean, there are many individual differences that one could – that one could look at. Gender is one of many. We certainly do not want to suggest that we think or that the evidence suggests that there are always differences between men and women. Rather, we would posit that asking the question is important because sometimes there are key differences that really should inform policy and clinical care. Sometimes, in fact more often than not, it seems that men and women are more alike than different. Sometimes we just do not have enough information to make those calls yet.

Let me pull out some examples just to kind of underscore this point. In 2012, Sally Haskell and her colleagues published a study comparing male and female veterans. I believe this was OEF/OIF era, and showed that women veterans were experiencing greater rates of post-deployment musculoskeletal back pain and joint problems. There is an example and when you throw gender into the mix, you actually do see that gender seems to have an impact. 

On the other hand, Dawn Vogt and her colleagues in 2011 did a really, kind of first of its kind study looking at male and females’ combat exposure and how that influenced PTSD. Those findings showed that actually controlling for combat exposure, it appears that men and women are equally resilient to the effects of combat. That was looking one year post-deployment. 

In the unknown department, we asked the question do women veterans’ families experience the same or different effects of deployment as male veterans? Do not know. As we will see, there has been not a lot of research done to date in this area. Although, it is definitely growing; and the preponderance of research that’s been done has focused on males and their families. We just do not have enough gender information or with information about women to actually draw conclusions about the potential for gender differences here. 

When we talk about gender differences, of course, if you are going to look at gender differences that assumes that you can conduct studies that have an adequate sample of women veterans. We know that can be challenging, both in VA and DoD and also requires persistence and creativity on the part of the investigators. Towards the end of the study, so we acknowledge that as maybe something that has been a limiting factor particularly in the past. We are also going to highlight some resources that are now in place that should facilitate this type of work moving forward.

Again, despite some previous barriers to including women in adequate numbers to examine gender differences in research, this graph shows that the field of women veterans’ mental health research has grown arguably exponentially over the past two decades. There have been a number of research initiatives that have supported this growth. That has spurred prior evidence reviews and really high quality peer reviewed publications that are now available in the literature. 

Now to briefly summarize those who have come before us. I mentioned, there have been three key evidence reviews of women’s health research conducted over the past decade and I want to set the ground work by giving you some highlights of those work – of that work, which really sets the stage, and helps us to contextualize the work that we did.

The first of those reviews was conducted, it was published actually in 2006 by Goldzweig and colleagues. That review focused on women veterans’ health research published between 1978 and 2004. Almost a two decade span there, and they found 182 relevant studies, two of which were randomized controlled trials, the majority of which were observational studies and about half had a mental health focus, mostly PTSD and looking at military sexual trauma. 

Key gender findings here; again, I am focusing kind of on the mental health outcomes. Predictors of PTSD appear to be similar for both genders. Although you may see higher rates of one versus other types of traumatic stressors across genders, both male and female, for both males and females, combat sexual trauma are predictive of PTSD. They also noted higher rates of mental and medical co-morbidity among women. Then with regard to receipt or utilization of VA care. When gender specific care was available, so, for example, when the VAs offered annual exams, it appears that women’s use of VA services increased. It is important to note that at the time that this study was done, and a lot has changed since 2006. Not to mention 1978 when these – when these studies were first conducted.

But over the past decade, we have increasingly seen that VAs offer healthcare clinics specifically for women and provide a continuum of health and mental health care for women. It is I guess encouraging to see that we see a lot of more uptake at least these investigators noted more uptake when gender specific care was available. We know that is something that VA is focused on and is providing in gusto. 

Ok, so that next review up on the docket list was conducted; I guess completed in 2010. This was by Bevanne Bean-Mayberry and colleagues. These are both groups by the way coming out of the West L.A. VA, where there is a very strong VA funded evidence based synthesis program. This study, this evidence review focused on the – basically kind of picked up where the first one left off. They focused on the literature relevant to women veterans’ health published between 2004 and 2008. 

They found 195 relevant studies. Actually more studies published in a four-year period than had previously been published in two decades. A lot of the patterns were the same. There were relatively few randomized clinical trials or experimental studies. Most were descriptive and observational. About half of the studies had mental health content. Most of that content was relative to PTSD, depression, and military sexual trauma. 

Of the RCTs, I think a notable one was a randomized controlled trial conducted by Pollishner and colleagues. It was a multi site trial. It was published in JAMA in 2007. It was intervention study comparing prolonged exposure and present-centered therapy in women veterans with PTSD, the majority of whom had PTSD related to some sort of sexual assault. With regard to specific findings, they found higher rates of PTSD among OEF/OIF era women, but that risks and resilience factors were pretty similar for men and for women. For example, for both men and women pre-deployment assault histories were associated with increased rates of combat-related PTSD. 

Also, for both higher levels of social support decreased the odds of developing PTSD. Other PTSD risk factors were consistent for men and women, including childhood maltreatment, childhood sexual abuse, and adult sexual abuse. Overall, this review helped us to understand that while rates of PTSD, and risks and protective factors for PTSD are similar for men and women, women appear to be somewhat more likely to present with both psychiatric and medical co-morbidities. The study also highlighted the need to at the time to increase knowledge about VA care among non-users. 

We were seeing some knowledge gaps persisting about the type and quality of care that VA provides, about eligibility criteria, and the full breadth of availability of care options for women. Again, those gaps were really among those who were not using VA. Kind of a similar pattern that we see throughout, that those who access VA care seem to have a very positive experience, men and women, so there’s more of a knowledge gap than anything else out there. That gap I think is closing.

Ok, the last of prior reviews was conducted by Atumen, et al. published in 2011. This was a more circumscribed review. This was also conducted with the West L.A. evidence synthesis program and they evaluated 44 studies. They were focusing specifically on mental health and reproductive effects of deployment in OEF/OIF era women. Kind of similar trends again; not surprisingly not a whole lot of randomized controlled trials, or experimental trials. They found 13 mental health studies, PTSD, and depression predominating.

Key gender findings: so, they looked at OEF/OIF women and compared in terms of men versus women. Men – women were accessing less care for non-PTSD mental health disorders than men. Younger women were less likely than younger males to use VA mental health services, although older women were more likely to use VA as compared to their male counterparts. We noticed that suicide risk was lower among women veterans versus males, but higher than non-veteran women within the general population.

We have you kind of take a step back at this point. Look at the work, tremendous amount of work done by these prior reviews. The picture that you see is that women accessing VA healthcare often present with significant psychiatric needs. Those are primarily, although not exclusively, related to PTSD and depression. We often also see co-morbid diagnoses and health impairments at rates that are somewhat higher than those seen in men and higher among women with PTSD as compared to non-PTSD disorders. Those kind of in very broad strokes with the lay of the land before we conducted our review.

That brings us to our review. Again, this was – this review was conducted under the charge of one of the key milestones that the VA and DoD integrated Strategic Action, the group on focusing on gender differences. That work group is the one that we are primarily involved in was asked to conduct. What we did was picked up where others had left off. In fact, in our – in our large report that is, I think, 155 pages or something like that, we actually summarized , of course, where, what other reviewers have found as a way of contextualizing our newer findings. We focused our systematic review by picking up where the Bean-Mayberry, et al review left off. We looked at 2008 through July of 2011. Although we admitted study – omitted studies that had been included with the Batuman, et al review because there was a little bit of overlap there. We also supplemented our review, our database lit search with bibliographic reviews and consultation with subject matter experts. 

We benefited. We were incredibly lucky. The West L.A. VA evidence synthesis program volunteered or could lend us their methodological expertise. We were able to use actually the same medical librarian who conducted their reviews conducted ours, or, updated that review for us; so, same databases and same search terms were used for our review as had been used for the Bean-Mayberry review that was – that had focused on 2004 through 2008. We absolutely were able to in terms of that lit search and the methodologies pick up right where they had left off. We focused on women’s mental health specifically but we were inclusive of all eras of service, not just OEF/OIF. 

Basically, inclusion criteria were peer reviewed articles focusing on or including women veterans in mental health. As you will see, we organized the content based on how prior reviews were conducted but also, just on how the findings fell out and made sense. We organized them into five different categories that I will touch upon in a moment. 

This slide shows our data flow. Once the database search, again looking at published relevant literature between 2008 and 2011 turned up 375 articles. Off the bat looking just at the abstract and title level, we were able to reject or omit 288 of those. That is largely because we cast a wide net. We used the same search terms as a prior review that was broader that had looked at health and mental health outcomes and effects, whereas we were just looking at mental health effects. The majority  – for the majority of cases the reason something was rejected was either it was not human,  it may have been an animal model, or in the majority of cases it was because it was health but not mental health related. That led us to 87 articles for full text review. Of those, 55 were rejected after full text review and full text review was conducted by two independent investigators on our team.

This is, I think a pretty normal stream that you see about two-thirds of the articles that you look at in full text end up not being included. We have listed the reasons for exclusion there. Sometimes there was overlap of the prior review. The sample or the content criteria were not specific to our research questions. In the end we end up with 32 articles: five categories that we kind of parsed these into for reporting. One, screening and prevalence of mental health conditions. Two, risk factors or vulnerabilities associated with mental health conditions. Next, medical and functional impairment associated with mental health conditions; mental health utilization, and barriers to care, and satisfaction of care.

In very broad strokes, so what did we see?  We saw no big surprises. A lot of the same trends that we saw in previous reviews including some limitations. We all know that intervention and longitudinal studies are expensive and complicated to run. It is not surprising that we saw relatively few intervention studies. The majority were sort of descriptive and cross sectional studies. Another limitation of the most of the studies that we looked at, which is true of previous evidence reviews, is that they predominately include VA healthcare users, so we know a lot more about women who are accessing our care system than those of the general community. 

Most of the studies were mixed gender as opposed to being women only. Within those mixed gender studies, we often saw high rates of more males than females, which I think would be expected. That is consistent with what we see just among our users and our population. A lot of studies used national databases. About half used national databases; about a third used select VAs. 

Although we broadened our criteria to include all eras of service, again, not surprising given the 2008 through 2011 time frame we were looking at, most of the studies examined OEF/OIF era samples. I mentioned five categories that we looked at. The first, excuse me, was prevalence rate. I also I think mentioned that our full report is 155 pages, so there is just no way we are going to be able to stuff every last detail of information into this presentation. What we are trying to do is give you highlights and kind of a flavor for what we were seeing. 

As I mentioned before we are really hoping we are going to leave time at the end for questions. We are hoping that this will prompt a really fruitful dialogue, and that we are very interested to hear how those in the field are responding to this; questions that you have; suggestions that you have may inform future work.

With regard to prevalence, as noted in prior reviews that looked at prevalence rates, women continue to slightly outpace men on rates of co-morbid disorders. For example, Kate Iverson found in a sample of TBI positive veterans that women experienced 1.5 times the rate of co-morbid PTSD and depression as compared to males.

Women also show slightly higher rates of depression and non-PTSD anxiety disorders. Those data come from McGuinn and colleagues. Then Hawkins and colleagues noted that women show lower rates of alcohol and substance use disorders as compared to men. This I think is also consistent with what we tend to see in the civilian population, so probably not any big surprises there. Again, we saw that younger women were less likely to engage in mental health treatment as compared to older women. Then, turning to risk factors, for both genders repeated deployment increased risk for PTSD. Although for women veterans of OEF/OIF, you know, our current conflicts in Iraq and Afghanistan, those with mental health diagnoses report less social and financial support than their male counterparts on average. 

That finding seems to have some implications for clinical planning for these women. For women, older age was associated with greater PTSD prevalence and chronicity and that was not found for men. We do not know why that is. We have – there were two hypotheses that were offered by investigators. He found this finding. It may be for example, that older women have more lifetime trauma exposure. That is – that shows up post-deployment as greater PTSD, prevalence and chronicity. 

It may also be that older women have more firmly entrenched social and family networks and that the experience of deployment may be more disruptive for them, than for younger women who have less firmly entrenched networks. Those are hypotheses that are worth exploring.

Moderator:Sorry to interrupt. Can I ask you to speak up just a little bit.

Jennifer Strauss:Of course.

Moderator:Thank you. 

Jennifer Strauss:Ok, moving on; so, looking at functional impairment, utilization, and barriers. We looked at functional impairment for both genders. Post deployment trauma symptoms are associated with relationship disruption. That is probably not a surprise. A huge caveat there, the study that reported that that was – I think, the most prevalent, the most widely cited study was Steve Stares and his group, and that was by far a largely male sample. I think less than ten percent of that sample was women, included women, and their families. 

That begs that question of we do not really know enough to know if there are gender differences when it comes to the effect of deployment on relationships and on family functioning. Then among veterans with PTSD, women report more health and interpersonal impairment as compared to males. With regard to utilization and barriers to care, we seem to be sort of turning a corner here. The current review does show that OEF/OIF women using VA are younger and they show greater increase in primary care and mental health service use. 

There do remain some barriers to service, including service eligibility awareness, and perceptions of providers. But I want to sort of contextualize that by saying that the rates of primary care and mental health service use has been increasing steadily among OEF/OIF era since women in the past decade. We are seeing phenomenal increase in the uptake of women who are accessing VA services and when we ask women who are using our services, we will get to this in a moment, they have overwhelmingly positive views of that service. There seems to be a lot of reasons that one can infer for the increase and uptake of VA service. It seems like this increased awareness of service eligibility and VA has done a tremendous public service outreach effort to increase awareness about the availability and quality of care we provide for women. The numbers seem to suggest that is effective and that women who access our care are having a very positive experience.

That brings me to satisfaction with care. Ninety percent of those with a mental health diagnosis report a positive rating for the last appointment with VA. Again, overwhelmingly we see those who are accessing our care have a very positive impressions. When we do see lower ratings of care when they occur, they tend to be associated with demographic factors, minority status, younger age, and psychiatric factors such as bipolar disorder, substance use disorder, and PTSD. Of course, when we look at folks with PTSD I think we all appreciate that folks with that disorder often experience difficulty with trust and authority.

It may be that this difficulty is working its way into the exam or treatment room and may be influencing some of these care ratings that we are noting here. As compared to non-VA users, VA users report that their perception of VA care women is that it is just as good as for women as it is for men. For example, Mengeling reported a – they asked about women’s health preferences and specifically asked a question about the perception that VA serves men and women equally well. 

Among those who use VA, about two-thirds say yes, they believe that men and women are equally well cared for by VA, whereas slightly less than half of those who do not use VA endorse this. Again, when we get people in the door and ask them about the quality of their care, and the quality of care for men and women, the majority are having very good experiences, and reporting that the care is equitable, and high quality.

Thinking about advances since prior reviews. What did our review kind of highlight that adds to – adds to what those who became before us had noted?  New women enrollees have significant health and mental health care needs despite their younger age, but they seem to be less likely to engage in mental health services than older women veterans or their own cohort of male veterans. This is particularly true for non-PTSD care. 

We also seem to have an increasingly sophisticated understanding of co-morbidity. If you went back two decades I think we were looking at disorder by disorder, PTSD versus depression, versus substance use. We have much more sophisticated and large database studies looking at, for example, rates of PTSD co-morbid with depression; dual diagnosis veterans and some of their special needs. That literature has grown phenomenally over the past several decades. 

We also know a good deal about barriers to care, including knowledge gaps, and great strides have been being made through public service and other educational mechanisms to educate those not accessing care about the very good quality and the breadth of care that we provide for women. Then in addition women veterans in VA have a generally positive view of the care. We are learning more about how – the way in which care is organized. For example, specialty clinics and integrated clinics affect satisfaction for care. Then referrals for care and hand offs between care environments. That is another area where we see a lot of growth.

To summarize key findings: we see consistently across reviews is that women using VA care have similar rates of mental health diagnoses as men, but we have some different gender differences in patterns. We see more depression among women and less substance use, and alcohol use in women as compared to the male counterparts. Those are rates that I think mirror what we see in civilian samples.

Women are still experiencing high rates of PTSD. It appears that this is accompanied by more health related co-morbidities and potentially less social and financial supports as compared to male veterans. That seems like clinically meaningful information that is worth follow-up. We also, when we look at the effects of deployment on families, there has been some initial studies describing these effects on males, but very little data looking at women, so that again, seems like an area for further development. We also know that veterans of both genders generally have positive views of VA care when they are enrolled in care. It appears that women may be more satisfied with care that is available in gender specific clinics, at least in some instances.

Potential areas for growth, and this is...  We are not writing this on stone tablets. This is – these are ideas. They are generating ideas. Again, hoping that we will generate ideas in the context of this conversation today and future dialogues. At this point there are a number of areas for which we have a really robust literature on descriptive information for males and females. That said, there seems to be a need for even more information specifically around substance and alcohol use disorders in women and also, severe mental illness in both men and women veterans. Also, the effect of military service and deployments on families in both genders. 

Similarly, and this is true for private sector as well as VA, we could – it seems like there would be a call for more information on factors that could contribute to increased mental health treatment satisfaction. What we know is good. There seems that more information would also, would help policy and clinical decision makers. Finally, we are increasingly appreciating the need for understanding best practices for gender sensitive mental health care. This is a particular focus of our section within VACO something we spend a tremendous amount of time thinking about and look forward to understanding further in the years to come.

We want to echo prior recommendations for growth put forward by previous investigators. There is a need for more intervention studies and longitudinal studies that examine the effects of treatment and factors associated with long-term remission and risk for relapse. Again, we are not the first to suggest that it may be worth expanding our outcome variables looking beyond diagnosis and symptoms to things like quality of life and level of functional impairment. 

Also, looking at how the organizational, the organization of how care is delivered. What types of environments; for example, single, mixed, integrated care environments. How that influences the efficiency, quality, uptake of care. Looking into the future, there is a lot of research. We have like – we have come a long way. Going back to 1978 and the initial review that was conducted by Goldzweig and colleagues. We now have a tremendous, strong, and very high quality foundation for research in this area. Enough so that we can now focus on strategies to reduce disparities and identify best practices, which is a lovely place to be. 

I mentioned earlier that we recognize that this type of work can be difficult. I want to point towards some initiatives that have been put into place that should facilitate the type of work that we hope to see in the future. For example, HSR&D has funded a practice based research network and women’s health consortium. These, guessing that many on the call are familiar with these resources. But these provide infrastructure and methodological and content matter expertise nationally for folks who want to study women only or conduct studies that have an adequate number of women that they are empowered to look at gender differences. 

Again, this is whole infrastructure and network in place to help folks interested in doing that, to conduct that level of research. There are a lot of surveillance and evaluation mechanisms in place. We know, for example, the MST support team does – monitors military sexual trauma. Patty Hayes’ group out of Central Office does a tremendous national survey on women’s health broadly. 

To toot our own horn, the women’s mental health section, our group recently launched, or fielded a national survey of best practices for gender sensitive mental health care. That was completed by staff at each mental health – or each facility – each VA facility by a mental health staff. We had 100 percent response rate. We are very proud of that and have just completed all data cleaning and data entry, and look forward to beginning to analyze results for the weeks to come. Also as mentioned, there is a very strong interdepartmental partnership between VA and DoD; and a lot of really good work and opportunities coming out of that.

With that I am going to catch my breath and pass the baton back to Natara.

Natara Garovoy:  Great, thank you. Before we conclude, I want to really just take a moment to share some of the most recent initiatives to which folks can stay up to date on women’s mental health issues. Either again sponsored by the mental health services out of VACO. But first we got – we have a launched a women’s mental health teleconference series. This was just launched in August. 

There’s been really strong and positive attendance so far, which is wonderful, really highlighting I think the need and interest in this specialty area. It is offered on the first Monday of each month. Our future plans are to make the audio recordings which are already happening as well as the PowerPoint slides of those presentations available on Internet, most likely through our women’s mental health SharePoint site, which is under construction.

The next resource I want to make folks available – make folks aware of that is available currently is the national women’s mental health distribution list. This initiative just launched last month. In fact, that the numbers keeps growing. I think we are up to over 450 members now. Any requests to join that distribution list can be sent directly to me at Natara Garovoy which is n a t a r a dot g a r o v o y at v a dot gov. 

Next slide, please. For any questions or comments, I know we are going to be using the last few minutes. I think there is actually time saved even beyond the hour for any questions or comments folks have on the presentation, but for anything even moving forward, if folks would like to contact either myself or Jennifer, feel free to use the contact information on your screen. With that, I would like to thank everyone for their attendance this morning. I look forward to our questions and discussion.

Moderator:Great, thank you both very much for that in depth presentation. We do have roughly ten questions pending so we will just jump right into those. The first one received. Do all VA hospitals have women-only IP treatment?  Or it is just mental health or COD?

Natara Garovoy:  Hi, this is Natara. Could you repeat the question?  I think I might be a little unclear. I am not sure what is meant by some of the abbreviations.

Moderator:Do all VA hospitals have women-only IP treatment?  Is it just mental health or COD?  If you are not sure how to answer it, we can always have the person write in a little more in depth.

Natara Garovoy:  Yeah, I could take some educated guesses, but I would prefer to answer the question well. If it would be possible to get a little more information that would be helpful.

Moderator:Not a problem. The next one – in reference to slide eight, PTSD and non-PTSD, and anxiety, depression are listed as mental health disorders. Was MST included in that percentage?

Natara Garovoy:  That is a really interesting question. Again, this is Natara. I think one of the important caveats that we discussed. Quite often when it comes to MST is the difference between MST and the disorder, right, so MST is an experience and not a diagnosable condition. I can say that very likely MST, as a risk factor that may have led to one of those disorders was absolutely included but it is not a separate category. I hope that makes sense. I hope I answered the questions.

Moderator:Thank you very much. Gosh, sorry, I am having audio difficulties. Thank you for that response. The person who wrote in the first question did have – they wanted to explain the IP is inpatient.

Natara Garovoy:  Great.

Moderator:I am not sure if that helps. Do all VA hospitals have women-only inpatient treatment?  Is it just mental health or COD?

Natara Garovoy:  I think the answer is – the short answer is no, not all VAs have women-only inpatient treatment. But they do exist.

Moderator:Great, thank you. The next question; given the high rates of divorce and adjustment issues, when a woman deploys it definitely shows that there are vast differences and more complex than when a male vet deploys. That is just a comment there.

Ok, the next question. How do you classify the category of quote women for the review/meta studies?  Is it based on sex assignment at birth, which would then activate being labeled female or women as veterans in DoD and VA?

Jennifer Strauss:This is Jennifer. Is this a question?  I just want to clarify between, for example, sex and gender identity.

Moderator:I believe that is what they are getting at.

Jennifer Strauss:So, actually that is...  Because that is a really interesting area. I think we all know there is a lot of training and policies coming out around that. To my knowledge, all of the articles that we reviewed, I cannot speak to prior reviews in this level of the detail. But I think they really were defining a woman by her sex. We did not get into – there were no studies that we examined of the 32 that we examined that looked at gender identity per se. 

Moderator:Ok, thank you very much.

Moderator:Ok. How do you?  Sorry – How do you align this with HHS research being done on transgender people especially now that they are collecting data based on sex assignment at birth and current gender identity?  Now that the VA covers some trans-specific healthcare.

Jennifer Strauss:This is Jennifer again. What I – what I think is relevant. Again, none of the studies that we found in our literature review look specifically at this issue of gender identity or gender reassignment. I guess that is in terms of gaps in the literature, I think that would suggest that there has not been...  We did not identify anyway any empirical studies published on that issue. What may be worth mentioning is that the survey of gender sensitive best practices that we fielded that we mentioned towards the end of our talk. We actually did include several questions about not just women but how sites are creatively – how sites are welcoming transgender, lesbian, gay, transgender. I know those are different groups, but veterans into their facility and we were looking for sort of creative ideas; potential asking about educational needs, et cetera. We partnered with folks within VA who have expertise in this area when we were crafting our survey to make sure that we were asking those questions what is in the right way. I can certainly say that is something that is on our radar. Although it is not – it is not the focus of our group, there is a group within VACO that the focus is very directly on that topic. I think there is a partnership there, and a lot of sensitivity, and a lot of interest in understanding it more. Our evidence review did not tell us very much. But we are hoping that our survey will shed some light on the topic.

Moderator:Thank you for that response. People are wondering how they can get a full copy of the report.

Jennifer Strauss: The report, and thank you for wanting a full copy of our 155 page report. This report actually is currently being reviewed by IMHS leadership VA, DoD leadership. At the moment I do not think we could share a report. I believe however that we should be able to provide out of the report more of an executive summary of the report on our SharePoint site at a future point. But it needs to be cleared and finalized first. That said, if folks have particular questions about that content and they want to contact us offline, there may be some aspects of this that we can share but in a limited way because it has not yet been cleared.

Moderator:Thank you for that response. A couple of people just wanted to write in no questions. But this is a fantastic and helpful talk. Thank you very much. The next question.

Jennifer Strauss:Thank you.

Moderator:In your reviews were there any findings regarding gender differences in, and/or risk for suicidality?

Jennifer Strauss:I can take that one. One of the...  The answer is going to be that we cannot speak to that. Because when we were looking at topics although certainly suicide is – has a large mental health component, we really were focusing on diagnoses. Within our work group and in conjunction with our Department of Defense partners, both suicide and homelessness were areas where there are other groups focusing on those topics. 

We did not – we did not specifically do database searches looking at either of those. We found some studies where they might have, for example, that you see higher rates of risk for suicide associated with PTSD. But, we did not do a thorough sweep of the literature related to suicide. I do not think we can speak to that reliably. It was just a decision that that was something that was outside of our charge.

Moderator:Thank you for that reply. The next question we have: When you say minority status are you referring to race and/or ethnicity?

Natara Garovoy:  Hi, this is Natara. I am not entirely clear what is meant by the question, but I will take a guess. I am trying to figure out the places where we addressed that concept and certainly do in the beginning when we identified women veterans as potentially a minority group within VA. I think the answer would be it would fall alongside of those classifications. 

There are lots of subgroups that are minority groups within the VA patient population. If that does not answer the question then I hope the person will resubmit and clarify. Again, I would like to do that well.

Jennifer Strauss:That is also something. This is Jennifer – that maybe we can answer offline because I think it depends on the study. I think in some instances investigators looked at ethnicity. I thinks status versus race. I think there is actually some overlap. Because I think there’s some of both in the evidence base right now. We, when we were speaking, qe are speaking more about ethnic status and also minority status in terms of gender. But I think there is some of both.

Moderator:Thank you very much. That particular submitter did submit several questions. I will encourage them to contact you offline for further in depth discussion of some of the topics they have brought up. The next question: in regards to satisfaction with VA care is the 91 percent specific to mental health appointments?  Or does the 91 percent include care at various VA clinics?

Jennifer Strauss:That is a great question. The two studies that we found that looked at satisfaction actually looked at satisfaction with general VA care. There has not been to our knowledge a study that very specifically looked at satisfaction with mental health care. In fact, that is an area that we wished that there was a little more information about that was specific to mental health. But it is talking and predominately about just general care and the focus on primary care.

Moderator:Thank you for that reply. We are getting down to the last half dozen questions or so. I appreciate you staying on especially to our attendees as well. Do you have a recommendation for a brief quality of life measure?

Jennifer Strauss:No. However, I – that is my short answer. That is something we could probably field offline. I do recall that Paula Schnurr, I think she was the first author – published  a study within the last four years, looking at least at quality of life, suggesting quality of life outcomes of PTSD research that may have some good ideas. I would not call that a specific area of expertise, but I would be happy to do some investigating and help that investigator offline to come up with some good resources.

Moderator:Thank you for making yourself available. The next question: I would like to know how existential issues related to PTSD are being addressed?  Also, I would like to know if non-evidenced based modalities are being considered in the mental health treatment?

If either of you would like to pass on this question, we can address it later.

Natara Garovoy:  Hi, this is Natara. I mean, I think it is an interesting question. It may get a little bit beyond the evidence review. I think I am not clear if it is addressing physically that the literature and if there were papers that were addressing the types of PTSD treatments out there. Or if there – if the question has more to do about VA services more broadly?

Moderator:Not a problem. That person is still in the meeting. If they would like to write in and further clarify, then they are welcome to do so. 

Natara Garovoy:  Thank you.

Moderator:The next – yes, the next question: Do you know the racial composition of women in the military?  The percentages of white, black, and Hispanics, et cetera?

Jennifer Strauss:I do not. That is in the public... It may be in the public domain, but that is really a Department of Defense question and not a VA question in terms of active duty. My guess is that there are in the public domain.

Moderator:Thank you very much. The next question: I would like to know...  We got that one. When designing spaces for women’s mental health outpatient clinics are there or can you point me in the direction toward design considerations for space of – for spaces, for example, women only waiting rooms?

Natara Garovoy:  Hi, this is Natara. This is such an interesting question. Again, the national survey that we just conducted, we are hoping is going to shed light on exactly the different types of things that people are doing and what best practices and unique set ups people may be doing to help promote gender sensitive care. To answer that question thoroughly, I think I would have to say stay tuned. But if that person would like to engage in some brainstorming offline, I would be happy to do that.

Moderator:Thank you for that response. The next question we have. We are down to the last few. One person wanted to write in regarding the LGBT question. There are 28 LGBT staff groups within the VA system that may be used as resources for these issues. The Palo Alto site has an excellent LGBT group for both veterans as well as staff. I would like to thank the contributor for mentioning that. 

A person is interested in obtaining the reference list that you used. Do they need to wait for the full report?

Jennifer Strauss:Good question. If that person would not mind sending us a note offline. I just want to get clearance on that. But that seems like something that we could share.

Moderator:Great, next question: Are there any studies that include care at Vet centers?

Jennifer Strauss:No, to my knowledge not; again, I cannot speak to the prior reviews. But of the 32 that we looked at, no, none were published that included data in Vet centers.

Moderator:Thank you, we have two questions remaining. I appreciate you both staying on. Are there non-California based VAs doing any research work?

Jennifer Strauss:I wonder if that is because I have mentioned the West L.A. Evidence Synthesis program and of course we know that some of the PBRM, the Practice Based Research Network and Women’s Consortium is based on the West Coast. But the beauty of those is those are actual national level resources, so A, yes, we have a lot of research done nationally, including some of the major hubs of those Practice Based Research Networks are located throughout the nation. But yeah, there is a strong presence nationwide.

Moderator:Thank you for that reply. Ok, questions do keep coming in. We have got two more. Did you look at TBI with co-morbidity or at least how it impacted other diagnoses for mental health?

Jennifer Strauss:We did not, per se. so TBI would be a, really, predominately a physical trauma that has obviously mental health components. The only study that we looked at. We did not – TBI was not a search criteria for our review. However, we mentioned Kathy – Kathleen Iverson’s study looking at psychiatric co-morbidities among TBI positive veterans because she examined it. It was a large database study. She and her team examined psychiatric conditions in that group. That was the one study related to TBI that was included. Our review was not conclusive of all studies on TBI.

Moderator:Thank you for that reply. Our final question: has there been any research into children born to females after Iraq and the child’s medical issues?

Jennifer Strauss:That is a great question. I am not – Natara, if you know if?  I do not know of any. We did not turn up any in our – in our review. I wonder if that work is being done. I do not have data. I do not have information on that. But I think it is a really interesting question.

Natara Garovoy:  Yes, and I agree. I think it is a great question. It points in some ways to some of the things you talked about in terms of future directions with potential need and interests to learn more about the impact on families in general.

Moderator:Thank you, the one person did write in that both of their children after Iraq have issues, so we thank you for sending in your personal experience. Ok, so those are all the questions that remain. I would like to give either of you or both of you a chance to make any concluding comments.

Natara Garovoy:  Thank you, yeah. I am sorry to interrupt. You go ahead.

Jennifer Strauss:No, I just wanted to thank everybody. We had such wonderful questions. We hoped that we would – we would stir dialogue. I learned from the audience. I feel like that was achieved. I really appreciate everybody calling in and the quality of questions that you raised. They raised my awareness.

Natara Garovoy:  I would definitely second that and just add that for anybody whose questions were not thoroughly answered or if there is more discussion to be had, we certainly would, we certainly would welcome any offline dialogues. But do feel free to use the contact information and reach out to us.

Moderator:Well, thank you both very much. Thank you to our attendees who were able to remain with us for the entire time. As I mentioned, this call has been recorded. You will receive a follow-up e-mail with a direct link to the recording. You can feel free to pass it along to your colleagues. Furthermore, as you exit the session, a brief feedback survey will populate into your web browser. 

Please allow that to come up and respond to the quick few questions. We really do take your opinions into consideration. It does give you an opportunity to suggest further topics for our program. Please write in. Thank you again to everyone and this does conclude our session for today. Please feel free to look inside our HSR&D cyberseminar catalogue on the web page for future women’s health sessions. The next one is coming up on the 22nd of October at 12:00 p.m. We hope to see you there. Have a nice day, everyone. 

Jennifer Strauss:Thank you.

Natara Garovoy:  Thank you.

[END OF TAPE]

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