Disparities in mental health screening for veteran women with a new diagnosis of breast cancer.
Authors: Fleege Nicole Margo Grogan , Bunt Stephanie , Mecham Bradley , Holcombe Andrea , Quinlan Jeffrey , Howren M. Bryant 
Published: September 2024

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Background:
Compared to the general population, mental health disorders, including depression, are higher for Veteran women. Breast cancer (BC) is the most commonly diagnosed cancer in this population and up to 50% of women will experience depressive symptoms after diagnosis, associated with poor prognosis and survival. An increasing number of Veteran women live in rural areas, where access to behavioral health care may be limited. This study sought to evaluate rural disparities in mental health screening and follow-up evaluation after a new BC diagnosis.
Methods:
Women Veterans with a new BC diagnosis were identified between 2017 and 2021. Data for mental health screenings [Patient Health Questionnaire (PHQ)-2, PHQ-9, General Anxiety Disorder-7] were collected subsequent to the first BC diagnosis. Rurality was defined per the USDA Rural-Urban Commuting Area (RUCA) codes framework to determine rurality based on population density and commuting patterns. Data were abstracted from several large VA and non-VA datasets, including the Corporate Data Warehouse (CDW) Outpatient files, non-VA Care Medical and Pharmacy System files, Program Integrity Tool, and VA Informatics and Computing Infrastructure for Oncology. Rurality data was specified using CDW designations combined with ZIP-code-level USDA RUCA information. All categorical variables were analyzed using chi-square tests. Means were tested using t-tests.
Results:
14,225 Veteran women with a new BC diagnosis were identified. The mean age was 63.4 (SD 11.7). The most common documented race was White (30.6%), followed by Black (15.7%). 59.6% lived in an urban setting as opposed to rural setting (40.4%). In the entire population, only 14% had a mental health screening within 3 months of a cancer diagnosis. Veteran women living in an urban setting were more likely to be screened compared to those living in a rural setting (17.4% vs 9.2%, p < 0.001). For women screened within 3 months, most screened negative, regardless of rurality (76.1% rural, 75.7% urban). Of women who had a positive mental health screen within 3 months, only approximately one-third (31.8% rural, 34.2% urban) had additional screening regardless of rurality. However, for those with a negative initial screen, urban Veterans were more likely to have any additional screening (17% vs 10.2%, p = 0.001). PHQ-2 was the most common mental health screening tool used (73.8%) followed by a combination of PHQ-9 and GAD-7 (9.6%).
Conclusions:
Mental health screening within 3 months of breast cancer diagnosis is low for Veteran women. There is a significant difference in screening between rural and urban populations. It is critical to both improve mental health screening overall in this population and bridge the disparity gap between screening in rural and urban Veteran women. This may impact not only mental health but also breast cancer outcomes during the period encompassing treatment and survivorship.