SYSTEMATIC REVIEW OF WOMEN VETERANS’ UNIQUE M

HEALTH NEEDS

SPOTLIGHT ON WOMEN’S HEALTH, OCTOBER 10, 2012WOMEN’S MENTAL HEALTH SECTION, MENTAL HEALTH SERVICES
‐

Acknowledgements 

• Investigators:

Jennifer Strauss

Jennifer RunnalsNatara GarovoyMonica Mann‐WrobelSusan McCutcheonAllison RobbinsAlyssa VentimigliaVISN 6 Mental Illness Research Education and Clinical Centers WWorkgroup

• Contributors: Jenny Hyun, Kathleen Iverson, Jan Kemp, Linda Lipson

Paul Shekelle, Dawne Vogt and DoD/VA Integrated Mental Health Str

VETERANS HEALTH ADMINISTRATION 

Paul Shekelle, Dawne Vogt and DoD/VA Integrated Mental Health Str

Action #28 (Gender Differences) Work Group
Agenda 

• Provide overview of women Veterans’ mental health

• Introduce DoD/VA Integrated Mental Health Strategic

Action #28 — Gender Differences

• Present current evidence review

• Identify next steps

• Highlight new resources available

VETERANS HEALTH ADMINISTRATION 
Women Veterans Mental Health: Overview 

• Women Veterans are the fastest growing segment of eligible VHA us

• Yet, they continue continue to be

a minority minority of VA users as compared compared to male 

• As such, women Veterans may face unique challenges

• VA offers

a full continuum of mental health services:

– Outpatient: assessment, evaluation, psychiatry, individual and group the

– Specialty services: posttraumatic stress disorder (PTSD), substance use d

depression, homelessness

– Evidence‐based therapies available at all VA medical centers– In

patient and residential treatment

o

ptions (mixed

gender and women o

VETERANS HEALTH ADMINISTRATION 
Single Gender Versus Mixed-Gender Programs 

• VA recognizes that some Veterans will benefit from treatment in an e

where all of the Veterans are of one gender

– May help address

a Veteran’s concerns about safety

– May improve

a Veteran’s ability to disclose and address gender‐specific 

– May enhance treatment engagement and social support

• VA also recognizes that mixed

‐gender programs have advantages

– May help Veterans challenge assumptions and confront fears about the – May provide an emotionally‐corrective experience– Also promotes efficient use of resources: accepting both men and wome

treatment or admissions slots from going unused

– Women can and should have access to all services, and not be limited to 

treatment settings

• Given these considerations, VA does not promote one model over an

needs of

a specific Veteran dictate which model is most clinically app

VETERANS HEALTH ADMINISTRATION 
Women-Only Programs 

• Women Veterans can receive services at all VA medical centers• Some facilities facilities have established established formal outpatient outpatient mental health tre

tre

specializing in working with women Veterans

• Specific offerings vary from facility to facility, based on local demand 

• VA has residential and inpatient programs that provide treatment to 

or that have separate tracks for men and women

VETERANS HEALTH ADMINISTRATION 
Trend i sn Women Veterans’ f l 

’ Use of VA Mental He

and Clinical Presentations 

VETERANS HEALTH ADMINISTRATION 
T Di F l OEF/OIF/OND V 

Top 10 Diagnoses: Femal

e OEF/OIF/OND Vetera

2002-2012 (Q2=96,297) 

Diagnosis Pe

Wome

Musculoskeletal 

Mental Disorders (e.g., PTSD, Non‐PTSD Anxiety, Depression) 

Nervous System/Sense Organs Genitourinary System Digestive System Respiratory Endocrine System Diseases of Skin Injury/Poisonings 

Infectious Infectious and Parasitic Parasitic Diseases Diseases 

VETERANS HEALTH ADMINISTRATION Sourced from Epidemiology Pro

Health Group, Office of P
F d /O i I i F d /O i N 

t t

Women Veterans Mental Health: Operation EnduFreedom/Operation Iraqi Freedom/Operation Ne

(OEF/OIF/OND) 

Between 2002‐2nd Quarter 2012:

• 56.2% of discharged discharged female OEF/OIF/OND OEF/OIF/OND Veterans Veterans have accessed accessed V

54.2% of males)

• 51.0% of female OEF/OIF/OND Veterans seen at VA received a menta

diagnosis diagnosis (versus (versus 53.0% of males)

– Adjustment reactions (including PTSD) and depressive disorders among 

diagnoses for men and women

– Adjustment reactions: 31.5% of women versus 35.5% of men

– PTSD: 23.4% of women versus 29.1% of men*

– Depressive disorders: 27.1% of women versus 21.0% of men

*Research on PTSD among OEF/OIF/OND Veterans suggests women are 

effects of combat stress as men in the year following return from dep

VETERANS HEALTH ADMINISTRATION 
Ch i P f W V ’ U f VA 

Changing Patterns 

of Women Veterans’ Use 

of VA 

Health Services 

Between 2005

‐2010:

• Number of women who received received VA inpatient inpatient mental health care inc

inc

• Number of women who received care at

a VA Mental Health Residen

Rehabilitation Treatment Program(MH RRTP) increased 47.4%

• Number of women who received VA outpatient mental health care i

69.8%

• Overall Overall, proportion proportion of women Veterans Veterans who received received VA specialty specialty m

care increased 24.1% between 2005

‐2010

Women Veterans are increasingly accessing VA mental health se

VETERANS HEALTH ADMINISTRATION 
D Do /VA I d M l H l h S (IMH

/VA Integrated Mental Health Strategy (IMH

Strategic Action #28 — Gender Differences 

• DoD and VA identified the need for an integrated strategy for the pro

mental health care to military service members, Veterans, and their 

• IMHS resulted from recommendations from the 2009 DoD‐VA Menta

Summit

• 28 Strategic Strategic Actions Actions focused focused on establishing establishing continuity continuity between between epis

epis

treatment settings, and transitions between the DoD and VA

• Workgroup assigned to each Strategic Action, includes VA and DoD c

researchers, and policy experts

VETERANS HEALTH ADMINISTRATION 
D Do /VA I d M l H l h S (IMH

/VA Integrated Mental Health Strategy (IMH

Strategic Action #28 — Gender Differences 

IMHS SA #28: Gender Differences• Explore gender differences in delivery and effectiveness of preventio

health care for women and for those with military sexual trauma (bo

• Identify Identify disparities disparities, specific specific needs, and opportunities opportunities for improving improving t

t

preventive services

Systematic evidence review

VETERANS HEALTH ADMINISTRATION 
W V ’ M l H l h R h Women Veterans’ Mental Heal

th Research: 

Past and Current 

VETERANS HEALTH ADMINISTRATION 
The Importance of Including Gender in Research 

• Different: Women Veterans experience greater rates of post

‐deploy

musculoskeletal, back problems, and joint problems than men (Hask

• Similar: Women Veterans are as psychologically resilient to the effec

exposure as men (Vogt et al., 2011)

• Unknown: Do women Veterans’ families experience the same or diff

deployment deployment as male Veterans Veterans’ families? families?

VETERANS HEALTH ADMINISTRATION 
N b f P bli i Th I l d W V 

Number 

of P

ublications That Incl

u

d

e Women Vet

Mental Health Content 

4045503035402025

5

1015

05

VETERANS HEALTH ADMINISTRATION 

Adapted from Bean‐Mayberry et al., 2010; excludes non‐men
182 studies reviewed:

– 2 randomized clinical trials (RCTs), 180 observational studies

• Approximately half had a mental health focus

Prior Reviews: Goldzweig et al. (2006) 

State of women Veterans health research• 182 t di i d

– Predominantly PTSD and/or military sexual trauma (n = 43)

• Key gender findings:

– Predictors Predictors of PTSD similar similar for both genders genders (e.g., combat and sexual trau

trau

– Higher rates of mental/medical co‐morbidity among women– Women receiving receiving primary primary care in a VA women’s clinics clinics report greater greater sa

sa

those in general primary care

VETERANS HEALTH ADMINISTRATION 
Prior Reviews: Bean-Mayberry et al. (2010) 

Systematic review of women Veterans health research 2004

‐2008

•195 studies studies reviewed reviewed

–

5 RCT/experimental studies; all others descriptive/observational

– 85 mental health (PTSD, depression, military sexual trauma)

– 33

d l ep oyment

/post‐d l ep oyment h lh ea

t

h (some overlap

wi ht

h mental h 

ea

• Key gender findings:

– RCT of prolonged prolonged exposure exposure and present present‐centered centered therapy therapy in women Vet

Vet

1st VA multi‐site trial in women

– As compared to men, OEF/OIF women are disproportionately and/or mo

s

y p m

ptoms of PTSD, de

pression, and other mental health issues

– For both women and men, assault histories prior to combat exposure w

a two‐fold increase in new‐onset PTSD symptoms

– Knowled

g

e

g

a

ps,

particularl

y amon

g VA non‐users, exist re

gardin

g eli

gibi

VETERANS HEALTH ADMINISTRATION 

g g p

p

y

g

g

g

g

availability and quality of women’s health care
Prior Reviews: Batuman et al. (2011) 

Health effects of military service on women• 44 studies studies reviewed reviewed

– 

5 RCT/experimental studies; all others descriptive/observational

– 13 mental health (predominantly PTSD, depression)

– O /O EF IF only

• Key gender findings:

– OEF/OIF women accessing less care for non‐PTSD related mental health 

men

– Younger women less likely than younger males to use VA mental health s

older women are more likely to use VA as compared compared to male counterpar

counterpar

– Suicide risk is lower among women Veterans versus males, but higher th

within the general population

VETERANS HEALTH ADMINISTRATION 
Current Review 

Systematic review of gender differences in mental health and the uniqwomen Veterans• Database search for articles related to women Veterans, published 

January 2008 and July 2011, supplemented by bibliographic review 

consultation with Subject Matter Experts (SMEs)

• Employed same search terms and strategies as prior reviews

‐ Included Included: peer reviewed reviewed articles articles focused focused on or including including women Veteran

Veteran

health

‐ Examined: content included and organized by prevalence, risk factors, fu

impairments, h lth ea care utilization and b i arr ers, and satisfaction with VA c

VETERANS HEALTH ADMINISTRATION 
Data Flow 

375 Articles identified

288 rejected after abstract/title review

87 articles articles full text review 55 rejected rejected after full‐text review: review:

27 Sample criteria not met

6 Content criteria not met14 Study design not appropriate

8 Overlap with prior evidence reviews

32 articles assessedScreening Screening and Prevalence of Mental Health Conditions Conditions (n=10)

Risk Factors or Vulnerabilities Associated with Mental Health Conditions (n=7)

Medical and Functional Impairment Associated with Mental Health Conditions (n

Mental Healthcare Utilization and Barriers to Care (n=11)

VETERANS HEALTH ADMINISTRATION 

Satisfaction with VA Care (n=2)

(not mutua
–

Current Evidence Review: Results – Overview 

• Few intervention studies

• Primarily VA healthcare users

• Mixed‐gender but with preponderance of males

• 18 studies used national databases

– 13 studies studies used select VAs

• Most examined OEF/OIF or unidentified service‐era

VETERANS HEALTH ADMINISTRATION 
Gender Findings: Prevalence 

• Compared to men, women exhibit slightly lower PTSD rates and sligh

depression rates

• Women have higher rates of co

‐morbidity of disorders than male Vet

(e.g., PTSD and co

‐morbid depression)

• Older women (≥65) more likely to engage in treatment than younger • Women slightly less likely to receive

a substance use disorder diagno

VETERANS HEALTH ADMINISTRATION Sourced from Freedy 2010; Ma

Banerjea 2
–

Gender Findings: Risk Factors 

• For both genders repeated deployment increases risk for PTSD• Women Veterans of the current conflicts with mental health diagnos

less social and financial support than male counterparts

• For women, older age associated with greater PTSD prevalence and c

– More lifetime trauma exposure?

More deployment deployment‐related related disruption disruption of social and family networks? networks?

VETERANS HEALTH ADMINISTRATION Sourced from Fontana 2010; Mague
G d Fi di Gender Findings: 

Functional Impairment, Utilization and Barriers 

Functional Impairment:

• For both genders, post‐deployment trauma symptoms associated wi

disruption

– Limitation: largely male sample

• Among Veterans with PTSD, women report more health and interper

impairment than men

Utilization Utilization and Barriers Barriers:• OEF/OIF women using VA are younger and show greater increase in 

and mental health service use

• B i arr ers i l nc ude service eligibility awareness and perceptions ab t ou p

VETERANS HEALTH ADMINISTRATION 

Sourced from Frayne 2011; Fontana 2010; Haskell 2011

Friedm
–

Gender Findings: Satisfaction with VA Care • VA healthcare users have positive impressions of VA care

– 91% of those with a mental health diagnosis reported positive rating for 

appointment

• Relatively lower care ratings noted among:

– Disability status

– Younger age, minority

– Diagnosis of bipolar disorder, substance use disorders, or PTSD

• Compared to non‐VA users, VA‐users reported:

– Perception Perception of care as “good as” care for men

VETERANS HEALTH ADMINISTRATION 

Sourced from Burnett‐Zeigl
Advances in Knowledge Since Prior Reviews 

• Demographics:

– New women enrollees in VA care

youn

ger

– Minority status

– Use more medical services

• Increased co

‐morbidity knowledge

– Higher rate PTSD with co‐morbid

depression

– Mental illness with substance use

disorders

• Increased barriers knowledge

– Poorer perception of VA care among

non‐users

• Care organization organization may affect treatment treatment

– Integrated care increases mental health

treatment referral for women

VETERANS HEALTH ADMINISTRATION 
Summary of Key Gender Findings 

• Higher rates of non

‐PTSD anxiety disorders, depression, and medical 

among women versus men

• Less post

‐deployment social and financial support for women; new w

enrollees are younger

• Effects of deployment on families described for men but not women• Organizational barriers to care include availability of specialized serv• Generally positive views of care among VA

‐users of both genders

VETERANS HEALTH ADMINISTRATION 

Sourced from Banerjea 2009; Burnett‐Zeigler 2011; 

Friedman 2011; Haskell 2011; Ilgen 2010; 

Mengeling 2011. Washingto
Potential Areas for Growth in Research 

• Substance use disorders and serious mental illness• Co

‐morbidity of health and mental health conditions

– Traumatic brain injury, chronic pain

• Effects of deployment/military service on families and parenting• F t ac

tors

affecting sati

s

faction

with men

t l a

h lth ea care (VA an

d pri t va

t

e 

• Increasing understanding of ‘best practices’ for gender sensitive men

healthcare

VETERANS HEALTH ADMINISTRATION 
Building the Literature Through... 

• Increasing intervention studies• Increasing longitudinal studies

t

hat examine:

– Time‐course and co‐morbidity of disorders

– Effects of treatment

– Risk factors factors for relapse relapse

• Broadening outcome variables (beyond diagnosis and symptoms)

– Quality of life, level of functional impairment

• Examining organizational interventions

VETERANS HEALTH ADMINISTRATION 
– Strong inter‐departmental (DoD/VA) partnership

Looking to the Future 

• Foundation of research now well‐documented• Focus on strategies to reduce disparities/identify best practices• Initiatives Initiatives for further further research research and practice practice in place:

– Practiced‐Based Research Network (PBRN) and Women’s Health Consort

– Women’s Mental Health, Mental Health Services — national survey of be

gender‐sensitive sensitive mental health care

VETERANS HEALTH ADMINISTRATION 
Staff Education & Training Activities: 

• New women’s mental health monthly training calls for VA staff

– Initiative launched in August 2012– An average of 235 teleconference lines have been used for this call each 

– 

1st Monday of each month, Noon ET ‐ VANTS

# 20992

– Future plans: audio recordings and PowerPoint slides of archived presen

made available on the intranet

– Women’s Mental Health SharePoint site

– under construction

• National women’s mental health distribution list

– Initiative launched in September 2012

– 350+ members to date

– Requests can be sent directly to Natara.Garovoy@va.gov

VETERANS HEALTH ADMINISTRATION 
Contact Information 

• Jennifer Strauss, Ph.D.

508 Fulton Street, Building

6

Durham, NC 27705(919) 286

‐0411 ext. 5275

Jennifer Jennifer.Strauss@va Strauss@va.gov

• Natara Garovoy, Ph.D., M.P.H

795 Willow Road, MPD117

Menlo Park, CA 94025

(650) 493

‐5000 ext.

1

‐

2

‐22215

Natara.Garovoy@va.gov

VETERANS HEALTH ADMINISTRATION 
Thank You! 

VETERANS HEALTH ADMINISTRATION