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Bean-Mayberry B, Huang C, Batuman F, et al. Systematic Review of Women Veterans Health Research 2004–2008 [Internet]. Washington (DC): Department of Veterans Affairs (US); 2010 Oct.

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Systematic Review of Women Veterans Health Research 2004–2008 [Internet].

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AuthorSample CharacteristicsSample SizeDesign/ObjectiveMain MeasuresMain Findings
200728Female and male service members who deployed to OIF and completed post deployment health assessments (PDHA) and possibly post deployment helath reassessments (PDHRA)23,194
To document the frequencies of self-reported symptoms of and provider referrals during PDHAs among service members who subsequently showed evidence of PTSD
Responses to PTSD-related questions of PDHA’s and medical referral experiences of Operation Iraqi Freedom (OIF) deployers who were diagnosed with PTSD within six months after return from deployment; and/or screened positive for PTSD on Post Deployment Health Reassessment (PDHRA) questionnaires.-Among PDHA respondents, 24.9% were referred for health concerns of any type, 10.5% screened positive for PTSD, and 4.1% were referred for mental health concerns. Among PDHA respondents who were clinically diagnosed with PTSD within six months after deployment (n=2676), 54.7% had been referred for a health concern, 48.1% had screened positive for PTSD, and 27.0% had been referred for a mental health concern during their PDHAs.
-Females were more likely than males to receive referrals for health concerns in general and for mental health concerns specifically.
-However, females were not more likely to screen positive for PTSD during PDHAs. Female and male clinically diagnosed cases and possible cases (per PDHRA responses) of PTSD had a similar prevalence of screening positive for PTSD on their PDHA questionnaire.
Asmundson 2004149Female veterans obtaining general medical consults at one VAFemales 221Observational;
To evaluate the co-occurrence of pain and PTSD symptoms among women veterans.
PTSD symptoms using the PTSD Checklist Civilian version (PCL-C)-Pain-related variables were significant predictors of PTSD symptom cluster scores, including bodily pain, bothered by severe headache or migraine, and pain interference, as well as childhood trauma scores.
-The PTSD group had significantly higher values compared to the no PTSD group, and with the exception of bodily pain, the subsyndromal PTSD group had significantly higher values than the no PTSD group.
-Childhood trauma, pain interference, experience of sexual assault in the military and being bothered by severe headache or migraine were significant predictors of the re-experiencing symptoms.
-Childhood trauma, pain interference and experience of sexual assault in the military were significant predictors of avoidance/numbing symptoms and hyperarousal symptoms.
Becker 2006152Outpatient and inpatient female veterans who received treatment at the Durham VAMC.Females
To examine the effect of childhood risk/trauma indicators and the secondary effect of combat exposure in contributing to PTSD, depression, substance abuse and physical health status
Family loss and instability measured by the childhood events scale, childhood physical abuse, childhood sexual abuse, and combat exposure effect on PTSD symptom severity and physical health outcomes.Socio-demographic variables did not explain any of the dependent variables. Childhood physical and sexual abuse were significantly associated with PTSD symptom severity, while family loss/instability and childhood physical abuse were positively associated with negative physical health status. However, no effects were found linking childhood adversity variables with depression or substance abuse. Additionally, combat exposure did not show a mediating or moderating role regarding its relationship to childhood adversity or physical health status.
Benda 2005168Convenience sample of all homeless female veterans that entered an inpatient VA domiciliary program for substance abuse in a 3-year period. Systematic random sample of homeless men that entered program during same period.Females
(1) to study gender differences in predictors of readmission to inpatient drug treatment among homeless veterans because VA medical centers currently do not have services that are designed specifically for women; (2) are abuses at different stages of life span, combat exposure, and recent traumatic evens commensurate predictors, do employment, housing, family or friend relationships and spirituality mediate (3) or moderate (4) relationships between trauma and relapse.
Re-admission to inpatient drug treatment in a two-year follow-up.-Sexual and physical abuse in childhood or during active duty in the military and during the past 2 years were most potent predictors of readmission for women than men. Women’s readmission was heightened by increases in depression, suicidal thoughts, and traumatic events. Women’s readmission was lessened by greater family, friend, church or other support.
-Men’s readmission increased with greater substance abuse, aggression, and cognitive impairment. Men’s readmission decreases with employment stability and job satisfaction.
Berz 2008156Female veterans of the Vietnam war who had biological children who were a subgroup of the National Vietnam Veterans Readjustment Survey and had participated in the family interview component.Females
To examine the relationships between the posttraumatic stress disorder (PTSD) symptom clusters and parenting satisfaction in female Vietnam veterans.
Parenting satisfactionIn the multiple regression models, hyperarousal was the only symptom cluster which showed a significant and negative relationship with parenting satisfaction (p=.02). No other cluster had an effect.
Brailey 2007153Female and male active duty Army soldiersFemales
To describe risk and resilience factors potentially impacting troops prior to warzone deployment. Specifically, demographic, stressor exposure variables, and situational factors were measured in a large cohort of Army soldiers who had not yet been deployed to either OIF or OEF. As a situational factor, we focused on unit cohesion, a contextual military variable.
PTSD Checklist, Deployment Risk and Resilience Inventory, military unit cohesionRegression analysis revealed that life experiences and unit cohesion strongly and independently predicted PTSD symptoms, and that unit cohesion attenuated the impact of life experiences on PTSD. Some military personnel reported significant pre-deployment, stress-related symptoms. These symptoms may serve as vulnerabilities that could potentially be activated by subsequent war-zone deployment. Higher pre- deployment unit cohesion levels appear to ameliorate such symptoms, potentially lessening future vulnerability.
Busch 200477Female and male veteran VA users and non-VA population of employees and retirees with depression diagnosis and initiation of antidepressants*3028
VA Females

VA Males


To compare quality of pharmacotherapy for patients with major depression in the VA and the private sector
Quality of depression care pharmacotherapy (HEDIS measure of antidepressant medication management, e.g., proportion of patients with 3 or more follow-up office visits in 12 weeks after depression diagnosis)-More than 80% of patients who began antidepressant treatment achieved guideline-level acute-phase treatment.
-Few differences in the quality of pharmacotherapy for depression were found between VA and the private sector, with VA slightly outperforming in prescription of antidepressants during acute (84.7% vs. 81.0%) and maintenance phases of treatment (53.9% vs. 50.9%).
-Patient characteristics associated with pharmacotherapy quality included being female, and having a comorbid diagnosis of substance use, bipolar disorder, or anxiety or adjustment disorder.
Butterfield 20017Female and male veteran and nonveteran patients ages 18–70 years with criteria for PTSD recruited from Duke University Outpatient Psychiatry Center and VA Durham Comprehensive Women’s Health CenterFemales
To evaluate olanzapine efficacy and tolerance over 10 weeks compared to placebo in noncombat PTSD patients
Compliance with dose, treatment related events reported, Barnes Akathisia Scale (BAS), abnormal involuntary movement scale (AIMS) weight gain, psychometric measures, PTSD assessments with multiple measuresPatients in both groups showed improvements in PTSD symptoms, but no between group differences in treatment response were observed and a high placebo response was found.
Campbell 2008164Female veterans or reservists from a VA hospital women’s clinic in a large Midwestern city.Females
To examine the co-occurrence of childhood sexual abuse (CSA), adult sexual assault (ASA), intimate partner violence (IPV), and sexual harassment (SA) in a predominantly low-income, African American female veteran sample, and the detrimental impact of that collective violence on their mental and physical health.
Four forms of violence; CSA, ASA, IPV, SA; and Post-Traumatic Stress symptomatology (PTS)African-American female veterans were found to have experienced more violence than their Caucasian military counterparts, but their experiences are not markedly different than other low-income African- American women.
Copeland 2008198Female and male inpatients and outpatients sequentially recruited into the Continuous Improvement for Veterans in Care—Mood Disorders at one VA medical center.Females 61
To determine the association of insight and adherence in a large sample of VA patients with bipolar disorder, controlling for potentially confounding patient factors, to identify modifiable factors to improve care for these patients.
Scales comprised 8 questions in 2 domains to assess belief in the likelihood that medications or psychotherapy would be effective in achieving treatment goals, such as symptom relief and relapse prevention. Socio-demographic factors, medication adherence (2 measures), substance use, symptoms, and service- connected status were also assessed.Among 435 patients with bipolar disorder, 27% had poor adherence based on missed dose and 46% had poor adherence based on the Morisky scale. In multivariable models, greater insight into medication was negatively associated with both measures of poor adherence. Odds of poor adherence increased for women, African Americans, mania, and hazardous drinking. The association of mutable factors—hazardous drinking, manic symptoms, and insight— could represent an opportunity to improve adherence.
David (2006)5Female veterans with PTSD at 1 VA clinicFemales
Clinical Trial; Evaluation of 12-week open trial of behavioral intervention with structured group psycho education and self-defense training. (All participants received the intervention.)Risk perception of assault, psychiatric symptoms (i.e., PTSD, depression, anxiety, and hostility scales), and specific self-efficacy parameters (i.e., general, interpersonal, activities, and self-defense scales) were measured at 5 time pointsSignificant and sustained improvement at 3 and 6 months after program for PTSD avoidance behavior and hyperarousal symptoms, decreased depression scores, and increased interpersonal self-efficacy, self defense self-efficacy, and willingness to participate in community activities
David (2004)184Female veterans with physical or sexual assault histories receiving outpatient mental health services at an urban VA clinicFemales 64Observational;
To ascertain beliefs about the potential value of personal safety/self defense training among women veterans with a history of physical or sexual assault.
Beliefs about value of personal safety/self-defense training1. Most traumatized female veterans believe that personal safety/self-defense training would be an effective and powerful addition to more traditional treatments for PTSD.
2. Study participants indicated they believe such training would positively affect their sense of personal safety, promote increased competence in thwarting future assaults, improve their self-esteem, confidence and assertiveness, and reduce avoidant and agoraphobic behaviors.
Desai (2006)197Female and male national sample of VA medical outpatients with no depression diagnosis or mental health visits in the past 6 monthsFemales
To determine the rates and predictors of screening, screening positive, follow-up evaluation, and subsequent diagnosis of depression among medical outpatients.
(1) screened for depression in the outpatient setting, (2) among those screened, the proportion who screened positive according to standard, instrument specific cutoffs, (3) among those screened positive, whether the patient received follow- up evaluation within 6 weeks, and (4) among those followed up, the proportion who received a depressive disorder diagnosis according to the External Peer Re- view Program (EPRP) chart review.Overall, 84.9% of eligible patients (n=18,245) were screened for depression in the past year. Of the 8.8% who screened positive, only 54% received follow-up evaluation, and of these, 23.6% (n=204) subsequently were diagnosed with a depressive disorder. Patients who were younger, unmarried, and had more medical comorbidities were less likely to be screened; however, if screened, they were more likely to screen positive. Male gender and greater medical comorbidity were associated with decreased odds of follow-up evaluation after a positive screen.
Desai (2005)58Female and male VA patient respondents to the National VA Customer Feedback Survey, identified as having a visit to a VA general medicine, primary care, or women’s clinic between March 1 – April, 23, 1999, who were not admitted to the hospital in the same time periodFemales
The objective of this study was to assess the role of psychiatric illness in satisfaction with outpatient primary care services in the VA.
core satisfaction with healthcare, including overall coordination of care among providers; open sharing of information with the patient; timeliness and accessibility of service; courtesy of staff; emotional support; coordination of care; specialist provider access; pharmacy access; and continuity of careAfter controlling for patient characteristics (e.g., gender, age, disability, acute vs. routine visit) and subjective health, patients with schizophrenia, post- traumatic stress disorder, drug abuse, depression, and other psychiatric disorders reported significantly lower satisfaction with their outpatient primary care. Dissatisfaction was particularly reported for access to care and overall coordination of care.
Dobie (2006)129Female veterans receiving care between 10/01/1996 – 1/01/2000 at VA Puget Sound Health Care SystemFemales
To determine associations between medical/surgical utilization and PTSD in female patients
Rates of medical/surgical hospitalizations, surgical inpatient procedures, and outpatient utilization for PTSD positive and PTSD negative women.Female veterans who screen positive for PTSD receive more VA medical/surgical services. About 33% of the women screened positive for PTSD. PTSD+ women had higher rates of medical/surgical hospitalizations of 20% vs. 14% overall. In particular, PTSD+ women ages 35–49 had significantly more mean hospital days compared to PTSD- women (43 vs. 17 days, p<.0001). Similarly, more PTSD+ women ages 35–49 underwent surgical procedures (5.9% vs. 1.7%, p<.001). Mean annual outpatient visits were also significantly higher among PTSD+ women (p<.001 for each comparison).
Dobie 2004160Female clinic patients who received care at the VA Puget Sound Health- care SystemFemales
To identify self-reported health problems and functional impairment associated with screening positive for PTSD in women in seen in VAScreen positive PTSD symptomatology, lowest quartile SF36V mental and physical component scoresPTSD symptoms are common among women treated at VA facilities (22% screened positive). Screening positive was associated with younger age and separated/divorced status.
PTSD is associated with multiple self-reported mental and physical health problems and poor health-related quality of life after adjustment for other patient characteristics.
Dove 2007171Women admitted to the TRISARF (at the Pacific Regional Medical Command facility) for all chemically addicted Department of Defense- eligible beneficiaries between the ages of 18 and 64 years.Females
To determine sociodemographic characteristics, coexisting conditions and referral sources of women in a substance use treatment center at a Pacific Regional Medical Command facility.
Admission to Tri-Service Addictions and Recovery Facility (TRISARF) for substance use treatment.Except for educational level, the military population’s sociodemographic characteristics did not differ from those of the general population. Seventy-eight percent reported a coexisting psychiatric condition, and the most frequently occurring conditions were depression and anxiety. Alcohol and nicotine were the two major substances of abuses with 76% and 85% respectively of the women’s records showing use of these substances. The smallest number of referrals was from primary care managers.
Erbes (2007)15Female and male OEF/OIF veteran enrollees (n=120) at one Midwestern VAMC who had returned within a six-month time frame, agreed to participate and completed a questionnaire17
103 Males
To evaluate levels of PTSD, depression, alcohol abuse, and the associations with quality of life, and mental health service utilization among returnees from OEF/OIF.
psychiatric distress levels (measured by PTSD symptoms, depression symptoms, and hazardous alcohol use), functional impairment, and service utilization1. PTSD levels (12%) were consistent with previous research while problematic drinking levels were also elevated (33%)
2. PTSD and alcohol abuse were associated with lower quality of life in multiple domains, even when controlling for depression.
3. Of those screening positive for PTSD, 56% reported using mental health services. Only 18% of those screening positive for alcohol abuse reported using such services.
4. No reported findings were identified as related to gender.
Escalona (2004)148Female veterans and non-veterans (i.e., veteran spouses) in one VA primary care clinic (Albuquerque, NM).Females 294Observational; To explore associations between trauma, PTSD and somatization among women in a VAMC primary care clinicPatients were defined as somatizers if they med abridged somatization criteria based on responses to the presence of six unexplained somatic symptoms from 35 possible based on DSM-IV criteria for diagnosis1. Traumatic events were reported by 81% of the women, with lifetime prevalence of PTSD at 27%, and somatization at 19%.
2. PTSD was the best predictor of somatization after controlling for demographic characteristics, veteran status and other mood and anxiety disorders. Of PTSD symptoms, psychological numbing was the strongest predictor of somatization.
Fontana 2006135Female veterans with consecutive admissions to the Women’s Stress Disorder Treatment Team (WSDTT) at 4 VA sites.Females
To examine the role of women’s comfort in coming for treatment of PTSD in a predominantly male environment
Female veterans comfort level when entering treatment and while participating in therapy, socio-demographic and clinical characteristics associated with comfort level, and strength of association of comfort level and participation and satisfaction with treatment.(1) Women treated for military-related stress disorder were “somewhat comfortable” in coming to the VA for specialized PTSD treatment from the start. The most important factor contributing to their level of comfort was the availability of a specialized treatment program for women. (2) Women who had prior contact with the VA reported no change in comfort level over the 8-month period. Women who did not have prior contact with the VA reported an increase in comfort from intake to 4 months. (3) Among women who did not have prior contact with the VA, those of minority ethnicity had significantly lower comfort levels, and, among women who did have prior contact with the VA, those with higher levels of education had significantly lower comfort levels. (4) Comfort level did not have a significant effect on their satisfaction with treatment.
Forman- Hoffman 2005174Female and male active duty personnel in the first Gulf War who were part of the Iowa Gulf War Study Case Validation studyFemales
To examine the patterns of coexisting (comorbid) mental disorders and whether comorbidity influences quality of life ratings in a sample of U.S. veterans.
Mental disorders were defined using the SCID- IV, and the Health Utilities Index Mark 3 (HUI3) was used to measure health-related quality of life (HRQoL).Over 35% of veterans with a current mental disorder had at least one other comorbid mental disorder. Those with mental disorder comorbidity had lower HUI scores than veterans with only one or less mental disorders (Mean 0.41 ± 0.30 vs. 0.72 ± 0.25, p < 0.0001.
Frayne 2006179National random sample of veterans in Large Health Survey of Veteran Enrollees (1999), who were sent a mailed survey of health and functional statusFemales
To characterize the health status of women (vs men) veteran VA patients across age cohorts, and assess gender differences in the effect of social support on health status.
All eight domains of veterans short form (SF-36) health status survey, mental and physical component scoresPhysical and mental component scores were similar by gender except among those age 65 or older, mean MCS was better for women than men (49.3 vs 45.9, p<.001). Patient gender had a clinically insignificant effect upon PCS and MCS after adjusting for age, race/ethnicity, and education. Women had lower levels of support than men: in patients aged<65, being married or living with someone benefited MCS more in men than in women.
Frayne 2004162Female veterans in the 1999 Large Health Survey of Veteran Enrollees, with self reported history of PTSD, depression, or neitherFemales
To examine the number of medical symptoms and physical health status in women with PTSD across age strata and benchmark them against those of women with depression alone or with neither depression nor PTSD.All 4 domains of the short form health status (SF-36V) scale used for physical health – physical functioning, role limitations due to physical problems, bodily pain, and energy/vitalityAcross age strata, women with PTSD (n=4348) had more medical conditions and worse physical health status than women with depression alone (n=7580) or neither (n=18937). In age-adjusted analyses, the physical component summary score was on average, 3.4 points lower in women with depression alone and 6.3 points lower in women with PTSD than in women with neither (p<.001).
Frueh 2007131Random sample of female and male veterans less than 80 years old at 4 VAMC primary care clinics selected in fiscal year 1999Females
To expand our understanding of PTSD prevalence, its psychiatric characteristics, and service use among elderly veterans in VA primary care clinics
prevalence of PTSD and psychiatric diagnoses by age; physical and mental health functioning by age; use of VA mental health services and disability benefits; identification of explanatory characteristicsThose in the 45–64 year age group endorsed the highest scores and those in the oldest age group (65 and older) endorsed the lowest scores, even after adjusting for the effects of race and sex. Similarly, those in the oldest group (7.5%) had one-third of the prevalence of major depression as those in the two younger groups (21.7% and 22.9%), and they had a lower prevalence of other psychiatric conditions, such as panic disorder, agoraphobia, social anxiety, and substance abuse. They also were about half as likely to show evidence of suicidal risk. In all cases, these differences were maintained even after controlling for relevant demographic covariates, such as race and sex. Those in the 45–64 year old group were generally more likely to meet criteria for most psychiatric disorders, followed by the 18–44 group, and then the 65 and older group. All but one of these relationships remained significant after adjusting for the effects of race and sex. The one exception was in rates of substance abuse/dependence between the 45–64 and 65 and older groups.
Gahm 2007161Female and male active duty personnel newly seen in a military outpatient mental health clinic between June 2003 and October 2004Females
The purpose of this study is to determine the relative contributions of demographics and reported childhood and adulthood trauma on screened PTSD and depression symptoms for soldiers in a military outpatient mental health setting.
Symptoms of PTSD and Depression, adverse childhood events (ACE) items, deployment risk and resilience inventory1) Univariate analyses indicated that more women met cutoff criteria for both PTSD and depression. Men more likely experienced a war or combat zone, witnessed an assault or kill, and to have been robbed. Women more likely experienced childhood sexual abuse than men. No gender differences in child physical abuse, witnessed parental violence, parental substance abuse, or experience of natural disaster occurred.
2) The regression model was significant for PTSD, with the experiences of combat (OR 2.09), witnessing someone being assaulted or killed (OR 1.88), and number of adverse childhood events (OR 1.25) emerging as significant risk factors. Witnessing some one being assaulted or killed (OR 1.56) and number of adverse childhood events (OR 1.34) significantly predicted screened depression status above demographic factors, but exposure to combat was not a significant predictor in this model.
Gahm 2008176Female and male active duty Army soldiers who entered an outpatient Behavioral Health (BH) clinic located in an Army medical treatment facility on a large military baseFemales
Observational; To describe the mental health characteristics identified through screening of soldiers seeking care during time of war in a military outpatient mental health setting, using the Behavioral Health Screening Instrument (BHSI).Findings on clinical scales (i.e. depression, anxiety, panic, PTSD, and alcohol use) and for demographic and psychological domains for soldiers seeking mental health services.Average mean scores were significantly higher for women on the following clinical scales: panic, depression, anxiety, and hostility. Men had significantly higher levels of both unit support and relationship satisfaction (p<0.01). There were no gender differences detected on the mean PTSD scores. 89.4% of the total sample screened positive for at least one domain of behavioral health difficulty. Both men and women reported low levels of marital satisfaction, although the mean score was significantly higher for men. Overall marital satisfaction scores were lower for the active duty soldiers than that of a studied depressed civilian population.
Gielen 2006192Female active duty personnel from all servicesFemales
Observational; To describe active duty military (ADM) women’s beliefs and preferences concerning domestic violence (DV) policy in the military.Beliefs about the consequences of routine screening and mandatory reporting; Policy preferences for routine screening and mandatory reporting119 women had experienced DV during their military service. A majority (57%) supported routine screening. Although 87% said the military’s policy on mandatory reporting should remain the same, only 48% thought abuse should be reported to the commanding officer; abused women were significantly less likely than non-abused women to agree with this aspect of the policy. ADM women’s beliefs were similar to those of women in a previously studied civilian sample, except that 73% of ADM compared to 43% of civilian women thought routine screening would increase women’s risk of further abuse.
Gold 2007155Female veterans of the Vietnam war and their male relationship partners who were a subgroup of the National Vietnam Veterans Readjustment Survey and had participated in the family interview componentFemales
Observational; This study examined relations between posttraumatic stress disorder (PTSD) symptom severity and several family adjustment variables among female Vietnam veterans.Correlation between PTSD symptom severity and marital adjustment, family adaptability, family cohesion, parenting satisfaction, and abuse, well being, and child behaviorA negative and statistically significant correlation was found between female veteran’s PTSD symptom severity and marital adjustment (r=−.38, p<.01), family adaptability (r=−.40, p<.01) and cohesion (r=−.34, p<.01) and parenting satisfaction (r=−.31, p<.01). However, for the male partner, PTSD symptom severity was only significantly correlated with male ratings of veteran’s psychological abuse (r=.21, p=.02).
Greenberg 2004137Female veterans entering outpatient treatment for PTSD at one of 4 VA Women’s Stress Disorders Treatment Programs (Boston, Brecksville, Loma Linda, New Orleans).Females
Observational; To examine the strength of association between continuity of care and health outcomes for female veterans newly entering outpatient treatment for PTSD.Changes in clinical status between program entry and four months follow-up on 11 measures (e.g., PTSD symptoms, general psychiatric/physical health, alcohol and drug abuse, violent behavior).1. Few significant associations between continuity and outcomes were found.
2. Four months after program entry, only commitment to treatment (treatment process) was positively associated with one or more continuity of care measures.
3. Severity continuity of care measures were associated with poor health outcomes.
4. Eight months after program entry, patients with greater continuity of care during the first four months of treatment had greater declines in violent behavior and PTSD measurements and larger increases in global functioning.
5. However, corrections for multiple comparison resulted in no statistically significant relationships, demonstrating only weak and inconsistent evidence of the clinical benefits of continuity of care for women entering care for PTSD.
Grubaugh 2006130Randomly identified female veterans who attended primary care clinic in any of the four VA sites in fiscal year 1999 (Charleston and Columbia, SC; Tuscaloosa and Birmingham, AL)Females
Observational; To examine rates of medical and psychiatric disorders among female veterans, the recognition of such disorders by VAMC care providers, and the use of relevant medical and mental health services by women both within and outside of the VA settingFrequency of psychiatric diagnoses, diagnostic accuracy, and medical comorbidity; Frequency of medical disorders and medical and psychiatric comorbidity; Functioning (SF-36 mental & physical health composite scores); Use of VA Health Services by psychiatric diagnosis; Use of outside careForty-four percent (43.9%) of women met criteria for at least one psychiatric disorder; 34.0% of these women met criteria for two or more additional psychiatric diagnoses, and concordance rates between interview and chart diagnoses were low. Ninety-five percent (95.2%) of women had a medical condition noted in their charts; 86.6% had two or more additional medical conditions, and a significant number of women had both medical and psychiatric diagnoses. Forty-four percent (43.9%) of women with an identified mental health condition received specialized mental health care by the VA in the past year.
Gutierrez 2006169Female and male soldiers who were processed for demobilization from military service between March 17, 2003 – November 3, 2003, through Fort Bliss, TexasFemales
Observational; To identify predictors of risky alcohol use and alcohol-related consequences among postdeployment soldiersPrevalence of self-reported alcohol related consequencesSignificant predictors of greater alcohol-related consequences, as assessed with the CAGE questionnaire, included fewer years of formal education, male, not being in an intimate relationship, racial/ethnic minority status, enlisted rank, having been deployed to the continental United States, and greater stress [χ2(8,5,458) = 235.991; p < 0.001]. Drinking and driving was more likely among soldiers who were male, not in a relationship, and reporting more stress than others in the sample [χ2(8,5,384) = 50.241; p < 0.001].
Halek 2005142Female and male veterans who applied for posttraumatic stress disorder disability benefits.Females
Observational; To determine the incidence of spontaneously reported emotional distress caused by the survey and to see whether survey recipients experienced proximal increases in health care utilization relative to unsurveyed controls.PTSD symptomatology, work, role, and social functioning, physical functioning, combat exposure and in-service sexual trauma, exposures to postservice traumas and hardshipsTwenty-six percent of all surveyed veterans made a total of 1,542 spontaneous comments. The overall incidence of spontaneously reported emotional upset, however, was quite low, just 2.7% spontaneously reported experiencing emotional upset. Surveyed veterans spontaneously reporting emotional upset were more likely to be female and of American Indian or Native Alaskan race/ethnicity. They had more severe PTSD symptomatology and more exposures to postservice traumas and hardships; they were also substantially more likely than other respondents to say they had experienced an attempted or completed sexual assault while they were in the military. In general, both surveyed and unsurveyed veterans showed reduced outpatient health care use in the postsurvey period relative to the presurvey period.
Himmelfarb 2006166Female veterans enrolled at a comprehensive women’s program at the VA West Los Angeles Healthcare Center or invited by letter to participate in the study.Females
Observational; To examine the prevalence and increased risk of posttraumatic stress disorder (PTSD) related to military sexual trauma (MST) and nonmilitary sexual traumaPrevalence of sexual trauma; time period of sexual trauma and association with PTSDSeventy-two percent of the sample had experienced sexual abuse. Military sexual trauma was significantly associated with PTSD (OR 4.30, 95%CI 2.30–8.00). The relative risk of participants with MST developing PTSD was almost 2 ½ times (RR=2.40) that of participants without MST. For those with postmilitary assault, the relative risk of developing PTSD was a little over 1 ½ times (RR=1.62) that of those without postmilitary assault. However, premilitary sexual assault (OR 3.52, 95%CI 1.64–7.57) and MST (OR 1.99, 95%CI 1.01–3.95) were each associated with post-military assault.
Hoge 200713Female and male Iraq veterans, from four Army combat infantry brigades, surveyed 1 year after their return from deployment80 Females
Observational; This study evaluated the association of PTSD with physical health measures among Iraq war veterans 1 year after their return from deployment with control for combat injury.Past month symptoms of PTSD, depression, alcohol misuse, self-rated health status, sick call visits, missed work days, and somatic symptoms.Among all participants, 16.6% met screening criteria for PTSD. PTSD was significantly associated with lower ratings of general health, more sick call visits, more missed workdays, more physical symptoms, and high somatic symptom severity. These results remained significant after controlling for being wounded or injured.
The high prevalence of PTSD and its strong association with physical health problems among Iraq war veterans have important implications for delivery of medical services. The medical burden of PTSD includes physical health problems; combat veterans with serious somatic concerns should be evaluated for PTSD.
Kaplowitz 2006134Female and male veterans at least 20 years old who had used outpatient services in the VA New England Health Care System at least once between January 1998 and December 1999 and at least once between January 2000 and June 2001Females 2744
Observational; To examine the relationship between mental illness, health care utilization and rates of cholesterol testingreceipt of cholesterol testing; mental illness diagnosis; frequency of VA outpatient visitsAmong veterans using VA outpatient services infrequently, those with mental illness were less likely than non-mentally ill control subjects to receive a cholesterol test during the study period (first quartile adjusted OR [aOR]=0.45, 95% CI 0.37–0.54; second quartile aOR=0.50, 95% CI 0.45–0.57). Mentally ill subjects with more frequent utilization of VA services were as likely as (third quartile aOR=1.01, 95% CI 0.91–1.13) or more likely than (fourth quartile aOR=2.73, 95% CI=2.46–3.03) non-mentally ill subjects to receive cholesterol testing. Mental illness was associated with a lower likelihood of cholesterol testing in subjects who used fewer VA outpatient services. The observed disparity attenuated at higher levels of service utilization.
Kilbourne 2007195Female and male veterans in VA National Psychosis Registry (NPR) database who also completed the VA’s Large Health Survey of Veteran Enrollees (LHSV) subsection on health and nutrition behaviors.Females
Observational; To evaluate patient and medication treatment factors associated with self-reported oral health status in patients diagnosed with serious mental illness (SMI) in a large, national sample of patients in the Veterans Affairs (VA) health System.The study measured predisposing characteristics (race/ethnicity, education), enabling factors (unemployment, financial strain, smoking), treatment factors (use of tricyclic antidepressants or other medications) and oral health status (general oral health and dental problems that made it difficult to eat).-Sixty-one percent of persons with SMI self-reported fair to poor dental health, 34.1 percent reported that oral health problems made it difficult for them to eat.
-Patients who were not employed, experiencing financial strain, who smoked, who were prescribed tricyclic antidepressants, or prescribed selective serotonin reuptake inhibitors were more likely to report poor or fair dental health. These variables were also associated with having tooth or mouth problems.
Kimerling 2007180Female and male veteran outpatients who were treated in VA health care settings nationwide during 2003.Females
Observational; To examine (1) whether universal screening for military sexual trauma (MST) detects a substantial population of VHA patients who report MST, (2) whether a greater burden of medical and mental illness is found among patients who screen positive for MST compared with patients who screen negative, and (3) whether the burden of illness associated with MST varies by patient genderMST brief screening instrument items, physical health diagnoses, and demographicsScreening was completed for 70% of patients. Positive screens were associated with greater odds of virtually all categories of mental health comorbidities, including posttraumatic stress disorder (adjusted odds ratio [AOR]=8.83; 99% confidence interval [CI]=8.34, 9.35 for women; AOR=3.00; 99% CI=2.89,3.12 for men). Significant gender differences emerged. The association of PTSD to MST was almost 3 times stronger among women than among men. The link between adjustment disorders and MST was significantly stronger among men than among women. Alcohol disorders and anxiety disorders were more common among both women and men who reported MST, but the relation to MST was significantly stronger among women than among men.
Lambert 200626Female and males forming a case series1
Observational; To report a series of consecutive cases of PTSD affected combat veterans who were treated with the atypical antipsychotic agent aripiprazole (i.e., Abilify)Sleep disturbances, nightmares, anxiety in crowdsThe five cases combat-related PTSD treated with aripiprazole and either sertraline or cognitive-behavioral psychotherapy illustrate a significant improvement, but not total resolution of symptoms in most cases.
Lande 2007170Female and male participants were recruited from the Medical Center Brigade at WRAMC including two groups (1) clinical staff and (2) military patients.Females
Observational; To determine whether there are gender-based differences in alcohol use among US Army soldiers, and if so, to evaluate the role of alcohol education efforts in the military.Alcohol consumption patterns both in terms of frequency and quantity, potential consequence experienced by subjects after alcohol consumption, awareness of and knowledge about alcohol, and level of interest in educational interventions and alcohol-free living areasAlthough men were more likely to engage in “bolus” (binge) drinking, women exceeded established guidelines for safe alcohol consumption at a risk-adjusted rate nearly twice that of men. In addition, for individuals whose behaviors were not in conformity with public health guidelines for safe alcohol consumption, the severity of reported negative consequences was influenced by gender. Women initially experience greater psychosocial impairment, and—should harmful drinking patterns progress to alcohol dependency – they are at greater risk of injury, morbidity, and mortality than men.
Lang 2008150Female VA primary care patients at San Diego VAFemales 221Observational; To evaluate the relationships among childhood maltreatment, sexual trauma in adulthood, PTSD, and health functioning in womenPTSD and physical and mental health functioning1. Childhood nonsexual maltreatment and adult sexual assault were positively associated with PTSD.
2. Childhood nonsexual maltreatment and PTSD were significantly associated with poorer physical and mental health functioning.
3. Adult sexual assault negatively affected health functioning through its association with PTSD.
Lang 2006133Female veterans who received medical care from San Diego VA Healthcare SystemFemales
Observational; To examine whether current post-traumatic stress disorder (PTSD) mediates the relationship between exposure to childhood maltreatment (CM) and indicators of health and healthcare utilization in female veteransRelationship between PTSD, exposure to childhood maltreatment (CM) and indicators of health and healthcare utilizationIncreased emotional abuse (β =−.32, p = .02) was associated with poorer functioning on the SF-36 role-physical scale; increased emotional neglect (β = .27, p = .02) was associated with better functioning on the same scale. Higher levels of emotional abuse (β =−.32, p = .01) were associated with increased SF-36 bodily pain and greater odds of using pain medication in the past 6 months (OR = 1.14, p = .01). Greater physical abuse scores was associated with poorer SF-36 general health (β =−.24, p = .04), and CM was not associated with increased healthcare utilization. PTSD was shown to mediate the relationship between emotional and physical abuse and health outcomes.
Lang 200555Female veterans who utilized the VA San Diego Healthcare System in 1998 at five different sitesFemales
Observational; To examine the association between satisfaction with general medical services and trauma-related mental health symptoms in women.overall satisfaction with visit; satisfaction with the provider; satisfaction with the clinicThe majority of patients were pleased with care they received. Older age and better mental health were significantly associated with greater overall satisfaction. The association between PTSD symptoms and satisfaction approached significance. Only general mental health reached significance individually with both satisfaction with the provider and the clinic. Women with more PTSD symptoms appear to be more satisfied with their overall care and with their provider.
Lapierre 200722Female and male active duty soldiers, who participated in a reintegration training program after returning from Iraq or Afghanistan263
Observational; To identify rates of posttraumatic stress and depressive symptoms in soldiers returning from warSelf-reported levels of depressions, posttraumatic stress, and life satisfaction(1) Women comprised only a small sample (6%). (2) Shortly after deployment, about 44% of study participants reported clinically significant depressive and/or posttraumatic stress symptoms. Soldiers returning from Iraq reported somewhat more mental health problems and treatment seeking than soldiers returning from Afghanistan. (3) Being separated or divorced (vs. married) was associated with increased reports of posttraumatic stress and depressive symptoms. Compared to NCOs and officers, junior enlisted soldiers reported more posttraumatic and depressive symptoms. (4) Female participants were more likely to report depressive symptoms; however, gender was not a predictor for posttraumatic stress symptoms for either sample (OIF and OEF). (5) Soldiers seek help for the symptoms; however, only 16% of OIF participants and 13% of OEF participants with symptoms did so.
Lee 2007182Female veteran convenience sample drawn from a pool of veterans who were participating in ongoing women’s health and mental health research within a hospital setting.Females
Observational; To understand how sexual trauma influences examination-related distress in female veterans, with the goal of improving the provision of care for this population.Level of anxiety that women who had suffered sexual trauma experienced during breast, pelvic and rectal examinations, specifically relating to the gender of the provider. Prevalence of post traumatic stress disorder (PTSD) was also measured.-The women reported significantly more anticipated anxiety during breast, pelvic, and rectal examinations when clinician gender was male (p<0.001 for each exam). Severity of PTSD symptoms was generally unrelated to anticipated examination-related anxiety, except for rectal exam.
-Anticipated anxiety was found to be a function of both examination type and clinician gender but not of PTSD symptom severity. These findings emphasize the importance of screening for sexual trauma and the careful consideration of female veterans’ unique needs during sensitive medical procedures.
Mancino 2006146Female and male veterans recruited from a 5-week, referral-based, VA outpatient psychosocial treatment program for PTSD from one site.Females 5
Observational; To evaluate the quality-adjusted health status in veterans with posttraumatic stress disorder (PTSD)Association between symptom severity in veterans with PTSD and the quality-adjusted health statusThe relationship between the QWB-SA and depression severity was linear (BDI quadratic, p = 0.31) and the linear relationship was significant (p = 0.003). The relationship between the QWB-SA and PTSD symptom severity as measured by the M-PTSD was linear (quadratic M-PTSD, p = 0.33), and the linear relationship was significant (p = 0.02). The relationship between the QWB-SA and the PTSD symptom severity as measured by the CAPS was nonlinear (CAPS quadratic term, p< 0.05). Overall, an inverse relationship was found between the quality of well being and PTSD and depression symptoms in Veterans. No findings reported by gender.
Merrill 2006191Female and male US Navy recruitsFemales
Observational; To examine whether premilitary intimate partner violence (IPV) was associated with attritionMilitary attrition based on 4 year follow-up in the Career History Archival Medical and Personnel System database of the Naval Health Research CenterOverall, more than one-fourth of recruits reported premilitary physical IPV and more than two-thirds reported premilitary verbal IPV. Women reported more perpetration and receipt of IPV than men, and married or cohabiting respondents reported more IPV than single respondents. Both perpetration and receipt of IPV significantly predicted attrition within 4 years. However, after controlling for other forms of IPV, only receipt of physical IPV significantly predicted attrition. In only one analysis did associations between IPV and attrition vary according to marital status or gender; premilitary receipt of verbal IPV had different effects on women and men.
Miller 2006132National sample of female and male VA users during FY 2000 with no evidence of nursing home treatment during FY 1999 or FY 2000, followed through FY 2003 using administrative claims data.Females
Observational; To determine whether patients with mental health diagnoses in the Department of Veterans Affairs (VA) are more likely to be admitted to nursing homes and to identify sociodemographic, utilization, and clinical characteristics associated with nursing home admissionRelationship between number of diagnosed mental illnesses and the risk of being admitted to a nursing homeAmong mentally ill patients, risk of admission was highest for those with any inpatient medical/surgical days (odds ratio [OR] 2.28, 95% confidence interval [CI] 2.13–2.43), followed by 3+ outpatient medical visits (OR 1.48, 95% CI 1.42–1.55), inpatient mental health days (OR 1.31, 95% CI 1.22–1.40), and outpatient mental health visits (OR 1.09, 95% CI 1.02–1.18). Patients diagnosed with dementia were 58% more likely to be admitted. Patients admitted to nursing homes were more likely to be older (P < 0.0001), men (P < 0.0001), white (P < 0.0001), single (P < 0.0001), had higher incomes (P < 0.0001), and suffered from greater service-related disability (P < 0.0001).
Mojtabi 2003138Female and male sample from National Collaborative Study of Early Psychosis and Suicide and comprised of U.S. Armed Forces personnel who had their first admission for major depression, bipolar disorder, or schizophrenia to a DoD hospital and were subsequently discharged from military services.Females
Observational; To examine the use of Department of Veterans Affairs (VA) aftercare services among patients with serious mental disorders who were discharged from the military after a first admission to the Department of Defense (DoD) hospital.Predictors of contact with VA versus no contact, and time to contact for those that do contact services.Fifty-two percent of 2,861 identified individuals had received outpatient care from VA mental health clinics by the end of September 1998. Women, older persons, and persons with schizophrenia or bipolar disorder were more likely to contact VA outpatient mental health services than men, younger persons, and those with major depression. Also, being female, older than 25 years at military separation and having a diagnosis of bipolar disorder or schizophrenia were predictors of contacting services: women were more likely than men to use services.
Monnier 2004151Female veterans identified from primary care clinics in four VA Medical Centers (Charleston and Columbia, SC; Tuscaloosa and Birmingham, AL).Females 191Observational; To examine the relationship between post tramatic stress disorder (PTSD) symptomatology, demographic variables, and functional status in US female veteransPost tramatic stress disorder (PTSD) checklist (PCL)After adjusting for other demographic covariates, PTSD severity was related to age (older patients reported less symptoms), and employment status (veterans who were not working due to disability reported significantly more PTSD symptoms than those who were working) for the female veterans. Additionally, after adjusting for relevant demographic covariates, greater PTSD symptomatology was related to worse functioning across both physical and mental health domains on the SF-36.
Murdoch 2007181Female and male active duty Army and other service membersFemales
Observational; To describe functioning and psychiatric symptoms of active duty men and women stationed on U.S. soil who did and did not report experiencing military sexual stressors.Sexual identity challenges measured using five items adapted from the gender role enforcement subscale of the Sexual Harassment of Men scale, sexual harassment, sexual assaultForty-five percent of men and 80% of women reported at least one sexual stressor type (i.e., sexual identity challenges, sexual harassment, or sexual assault). After adjustment, subjects reporting more types of sexual stressors had poorer physical, work, role, and social functioning; more-severe post-traumatic stress disorder, depression, and anxiety symptoms; and more somatic concerns, compared with subjects reporting fewer or no sexual stressor types (all p <0.004). Interactions by gender were insignificant (all p >0.11). Within sexual stressor category, men and women reported similar mean adjusted functioning and psychiatric symptoms.
Murdoch 2006185Nationally representative sample of females and males seeking VA disability compensation (for PTSD) between 1994 and 1998Females
Observational; To describe the association between post-traumatic stress disorder (PTSD) and in-service sexual harassment in a nationally representative sample of Department of Veterans Affairs PTSD disability applicantsHistory of in-service sexual assault, combat exposure, and adult exposures to serious postservice traumas and hardships, 3 items from sexual harassment inventory (SHI) criminal sexual misconduct subscale plus a fourth question about sexual assault unrelated to workAfter adjustment for other reported traumas, women’s reported in-service sexual harassment severity was significantly associated with PTSD symptom severity (p < 0.0001). The effect seen was about the same size as that seen for combat exposure among the men and for in-service sexual assault among the women. Men showed no association between in-service sexual harassment and PTSD (p = 0.33), although power was low for this test.
Murdoch 2005157Nationally representative sample of disability benefit-seeking male and female veteransFemales
Observational; To assess the impact of Veterans Affairs (VA) disability benefits for posttraumatic stress disorder (PTSD) on veterans’ odds of poverty, especially in women and African Americans.Receipts of VA disability benefits for PTSD or other, low incomeWomen were not significantly more likely than men to report low income. However, African Americans were more likely to report low income until adjustment for VA PTSD benefit was included.
Murdoch 2005159Female and male representative, eligible veterans who file PTSD disability claims between 1994 and 1998.Females
Observational; To determine whether previously identified regional variations in PTSD disability awards are explained by appropriate subject characteristics (eg. differences in PTSD symptomatology or dysfunction) and to estimate the impact of veterans’ PTSD symptom severity or level of dysfunction on their odds of obtaining PTSD disability benefits.Rates of service connection for PTSD; PTSD symptom severity and functional statusRegional variation in PTSD disability awards could not be attributed to regional differences in veterans’ current PTSD symptom severity or level of disability. PTSD symptom severity was associated with greater odds of service connection for PTSD (P<0.0001). Unexpectedly, poorer work, role, and social functioning and poorer physical functioning were each associated with lower odds of PTSD service connection (P<0.0001). Gender-specific data are only shown for the rates of service connection for PTSD by region.
Murdoch 2004188Nationally representative sample of females and males seeking VA disability compensation (for PTSD) between 1994 and 1998Females
To describe the prevalence of sexual assault among combat and noncombat veterans VA disability for posttraumatic stress disorder (PTSD).
Prevalence of sexual assaultIn this study, approximately 4% of males and 63% of females with combat exposure experienced sexual assault in-service. For non-combat exposed veterans, approximately 13% of males and 75% of females experienced sexual assault in-service. For males, post-service sexual assault was greater than in-service, and for women in-service sexual assault was greater than post-service.
Murdoch 2003158Randomly selected female and male veterans seeking VA disability benefits for PTSD between January 1994 and January 1998 who returned usable surveysFemales
To see if there are gender discrepancies in rates of service connection for posttraumatic stress disorder (PTSD) and, if so, to see if these discrepancies could be attributed to appropriate subject characteristics (e.g., differences in symptom severity or impairment).
Gender-specific estimated rates of service connection for PTSD, unadjusted and adjusted for socio-demographic characteristics, PTSD severity/functional impairment, in-service sexual assault status, and combat exposureA total of 3337 veterans returned usable surveys (effective response rate, 68%). Men’s unadjusted rate of service connection for PTSD was 71%; women’s, 52% (P < 0.0001). Adjustment for veterans’ PTSD symptom severity or functional impairment did not appreciably reduce this discrepancy, but adjustment for dissimilar rates of combat exposure did. Estimated rates of service connection were 53% for men and 56% for women after adjusting for combat exposure.
Ouimette 2004147Female and male patients in general medical and women’s health clinics at the Department of Veterans Affairs Medical Center in Palo Alto and Menlo Park.Females
To examine the relationship between PTSD and health in medical patients within the Department of Veterans Affairs healthcare system, specifically among medical samples such PTSD patients with different etiologic traumas.
PTSD severity and diagnosis, mental health conditions (depressive disorder, panic disorder, generalized anxiety disorder), other medical diagnoses, health related quality of life (physical function, role limitations, pain, energy), health risk behaviors (weight, smoking, alcohol consumption), demographics.-PTSD diagnosis and symptoms were associated with a higher likelihood of circulatory and musculoskeletal disorders. --PTSD symptoms were associated with more medical conditions.
-PTSD symptoms and diagnoses were also associated with poorer health related quality of life. Most findings remained significant after controlling for comorbid mental health conditions.
-Overall, gender did not moderate the relationship between PTSD and poorer health.
Pierce 1998178Female, Gulf War, Air Force veteran mothers of minor childrenFemales 263Observational;
To examine the predictors of children’s adjustment problems in data collected from a representative sample of Air Force mothers two years after the Gulf War.
Strains in major life domains (job, financial, parenting, etc); mental health and well-being of mothers (depression, anxiety, etc); wartime life changes and adjustment problems of children (amount of time spent away from military parent, number of life changes, children’s adjustment problems, etc.)The deployment of military mothers during Desert Storm was shown to put children of those mothers at risk for various adjustment problems. These risks increased significantly when the mother was deployed in the theater of war, when she experienced difficulties in providing care for the children she left behind, and when her deployment resulted in significant changes in her children’s lives.
Polusny 2008124Female veterans completing an anonymous cross-sectional survey and enrolled in an outpatient VA clinic.Females
To examine the difficulties Identifying one’s emotions (alexithymia) in understanding the link between PTSD symptoms and negative health outcome in sexually victimized female veterans
Physical health complaints, VA urgent healthcare utilization, sexual trauma exposure (Traumatic Life Events Questionnaire; TLEQ), PTSD symptom severity, and alexythymia (Toronto Alexithymia Scale; TAS-II)A total of 57.5% reported a lifetime history of sexual trauma; 45.8% reported sexual trauma before age 18; and 32.2% reported sexual trauma after age 18. Hierarchial regression analyses showed that alexithymia independently explained unique variance in participants physical health and their visits to urgent care. These data suggest that emotion recognition problems may contribute to poorer heath outcome in sexually traumatized women veterans beyond what is explained by sexual trauma exposure, health risk behaviors and PTSD. Psychological interventions that enhance emotion identification skills for women who have experienced sexual trauma could improve health perceptions and reduce need for acute health care.
Riddle 2007175Female and male service members in a large US military cohort (the Millennium Cohort).Females
To describe the baseline prevalence of mental disorders in a large US military cohort
Baseline prevalence of mental disorders in a large US military cohort(1) Alcohol abuse defined by PHQ was the most prevalent mental health disorder identified in the cohort. (2) The prevalence of all disorders was higher in women when compared with men except for alcohol abuse. Women were at statistically significant increased adjusted odds of PTSD, major depressive disorder, panic syndrome, anxiety syndrome, and eating disorders. (3) Generally, populations at greater odds of mental disorders included women, young, and single personnel, and individuals with lower socio-economic status as measured by education enlisted rank, and length of service.
Rowan 2006140Female and male active duty Air Force Service Members seen in 8 outpatient mental health clinics during a 1-year periodFemales 393
To examine whether self-referred service members (SMs) are more likely to complete treatment than service members (SMs) referred by supervisors or those under-going commander-directed evaluations.
Referral source (self, superiors encourages, commander directed), rank, special duty status, diagnostic category, treatment status, recommendationsResults showed significant differences across all variables, with self-referred members being more likely to be older, single, higher ranking, and without special duty status, as well as to have a less significant axis I diagnosis. Self-referred members were less likely to have confidentiality broken and to have career-affecting recommendations made. The implications of these findings, in terms of targeting interventions to increase self-initiated help-seeking behavior, and recommendations for future research are discussed.
Sadler 2004190Female veterans who served in Vietnam and subsequent eras selected from comprehensive women’s healthcare centers’ registries at VA’s in Boston, Durham, Tampa, Minneapolis, Chicago, and Los AngelesFemales
To determine whether the type or frequency of intentional violence experiences among women during military service influences health status or healthcare utilization. Differences in utilization and health status were also examined while controlling for life span violence exposures and important patient characteristic confounders.
Exposure to trauma, including sexual assault and military experiences, socio-demographics, current medical and mental health conditions and treatments, outpatient healthcare utilization, health status,The type of violence women experienced was unrelated to differences in medical utilization. Women reporting repeated violence exposures during military service had significantly more outpatient visits in the year preceding the interview than singly or non-traumatized peers (16 vs. 9 and 8 visits, respectively, p ! 0.05). Repeatedly assaulted women also had poorer health status (p < 0.05), and more often reported a history of childhood violence (p ! 0.001) and post-military violence (p < 0.001).
Repeated violence exposure is a relatively common experience among women in the military, and this has substantial implications for their health.
Sadler 2001193National sample female veterans who served in Vietnam, post Vietnam or Persian Gulf War era and were in a VA registryFemales
To identify workplace factors associated with non-fatal physical assault occurring to women during military service, not in the context of rape or domestic violence.
Physical assault, sexual harassment, socio-demographic and environmental factorsWorkplace violence was a common experience for military women. More than three-fourths of participants (79%) reported experiences of sexual harassment during their military service. Over half (54%) reported unwanted sexual contact. Threatened or completed physical assault was experienced by 36% of women during military service. In regression analyses, multiple risk factors increased the odds of physical assault from 3 to 7 fold including: experiencing unwanted sexual advances or pressure for dates in sleeping quarters (7fold); experiencing hostile work environments (5fold); observing heterosexual sexual activities in sleeping quarters (4fold); and ranking officers making sexually demeaning comments or behaviors (3fold).
Sadler 2000194National sample female veterans who served in Vietnam, post Vietnam or Persian Gulf War era and were in a VA registryFemales
To identify differences in health related quality of life among women veterans who were raped, physically assaulted, (not in the context of rape or domestic violence), both or neither during military service.
Health related quality of life scoresNearly half (48%) the women experienced violence during military service, including rape (30%), physical assault (35%), or both (16%). Women who were raped or dually victimized were more likely to report chronic health problems, prescription medication for emotional problems, failure to complete college, and annual incomes less than $25,000 (p<.05) Those who had both traumas reported the most severe impairment, across all domains of health status.
Sajatovic 2006196Female and male patients were recruited as part of VA Cooperative Study #430, Reducing the Efficacy-Effectiveness Gap in Bipolar Disorder, a randomized controlled trial that compared an easy-access treatment program and usual VA care.Females
To evaluate factors related to medication treatment adherence.
Factors associated with self reported treatment adherence among veterans with bipolar disorder such as patient characteristics, features of the patient-provider relationship, and barriers to care.(1) Individuals with bipolar disorder who were non-adherent to medication were more likely to have current substance use disorder; alcohol was the most commonly abused substance. (2) Past substance use disorder does not appear to be associated with treatment non-adherence. (3) Individuals who were non-adherent to medication were less likely than those who were adherent to receive disability benefits. (4) Individuals who were adherent to medication had more prescriptions for different medications than those who were not adherent. No findings were reported by gender.
Schnurr 2008154358 male Vietnam veterans who took part in a randomized clinical trial of group psychotherapy for PTSD and 203 female participants who took part in a randomized clinical trial of individual PTSD treatment, in Department of Veterans Affairs settingsFemales 203
To explore gender differences in quality of life among patients with post-traumatic stress disorder (PTSD)
Quality of life, PTSD symptomsOverall quality of life was poor in men and women, and in general, they did not differ in quality of life or in how PTSD was associated with quality of life. The few statistically significant differences were small and clinically insignificant. For both men and women, numbing was uniquely associated with reduced quality of life.
Schnurr 20076Female veterans and active duty personnel from 12 sites (VA and non-VA)Females
Randomized Clinical Trial; To evaluate random assignment to receive prolonged exposure versus present-centered therapy by standard protocol for 10 weeksPTSD symptom severity-Prolonged exposure was associated with greater reduction of PTSD symptoms
-Prolonged exposure patients were more likely no longer meet PTSD diagnostic criteria
Schultz 2006186Female veterans randomly selected from patients enrolled in 1 VAMC women’s clinic who had 1 visit in past year, and community, convenience sample of civilian women from health and social organizationsFemales
The purpose of the study was to investigate childhood sexual abuse (CSA), adult-hood sexual victimization (ASV), and adulthood sexual assault (ASA) experiences in a comparison sample of female military veterans and civilian community members.
Rates of each type of sexual victimization (CSA, ASV, and ASA).Women veterans were significantly more likely than civilian women to report adult sexual assault [22%; x2(1, N = 220) = 15.985, p = 0.000]. Although comparable rates of CSA and ASV were found across groups, veterans more frequently reported a history of sexual abuse by a parental figure, longer durations of CSA, and significantly greater severity of ASV than civilians.
Sherman 2005136Sample veterans (and their female partners) who served in the Vietnam War, had a diagnosis of PTSD and service-connected disability for PTSD, participated in the PTSD program, and current cohabitation with a female partner recruited from two VA medical centers.Females
To perform an initial needs assessment of partners of Vietnam veterans with combat-related post-tramatic stress disorder (PTSD) and to assess the partners’ current rates of treatment use.
Partner treatment experiences and ratings of treatment needs; partners’ assessment of her need for individual treatment and the partner’s appraisal of family treatment being extremely important (yes/no).Although large majorities of partners rated individual (64%) and family therapy (78%) to help cope with PTSD in the family as extremely or very important, only 28% had received any mental health care in the previous six months. Significant predictors of desire for individual treatment included partner’s anxiety and patient-partner contact, and partner’s age and severity of the patient’s PTSD symptoms were significant predictors of family treatment. The most commonly requested service was a women-only group.
Shipherd 2005163Female and male Persian Gulf War military cohort returning from duty in 1991 and followed for 6 yearsFemales 102
This study examined self-reported symptoms of PTSD and symptoms of drug and alcohol use (SUD) in a large non-treatment seeking population of veterans upon return from the Persian Gulf War and over a 6-year period to test the self-medication hypothesis.
Factors associated with substance use and PTSD symptomsThose completing the survey at time T2 and T3 were more likely to be older, female, Caucasian, married, more educated, and a member of the Reserves or National Guard compared to non-completers. No difference in substance use or PTSD symptoms occurred between completers and non-completers. A drug problem at T2 prior to deployment and T2 PTSD arousal symptoms were predictive of T3 DAST scores, but these factors were not significant for MAST scores.
Smith 200823Female and male active duty military enrolled in the Millenium Cohort Study surveyed before and after the wars in Iraq and Afghanistan13849
To investigate prospectively the effect of military deployment and self reported exposure to combat on new onset and persistent symptoms of PTSD in a large population based military cohort
Self-reported PTSD symptoms (PCL-C);Over 40% of the cohort was deployed between 2001 and 2006; 24% deployed for the first time in support of the wars in Iraq and Afghanistan. Incidence rates of 10–13 cases of PTSD per 1000 person years occurred in the millennium cohort. New onset self reported PTSD symptoms or diagnosis were identified in 7.6–8.7% of deployers who reported combat exposures, 1.4–2.1% of deployers who did not report combat exposures, and 2.3–3.0% of nondeployers.
Smith 200810Female and male military service members previously deployed to Iraq and Afghanistan, exposed to combat, who had no PTSD at baseline assessmentFemales
To conduct a prospective investigation of the relationship between prior assault and PTSD in a military cohort deployed to combat in Iraq and Afghanistan.
PTSD assessment, assault history, assault history, behavioral risk factors, and combat exposure.-New-onset PTSD symptoms or diagnosis among deployed military reporting combat exposures occurred in 22% of women who reported prior assault and 10% not reporting prior assault.
-Among men reporting prior assault, rates were 12% and 6%, respectively.
-Adjusting for baseline factors, the odds of new-onset PTSD symptoms was more than 2-fold higher in both women and men who reported assault prior to deployment.
Stecker 2007167VA national databases were used to identify veterans receiving IOP substance use treatment, and veterans with substance use disorders attending primary care but not in treatmentFemales
To investigate gender differences among veterans receiving intensive outpatient (IOP) substance use treatment in a national VA sample and to compare women attending IOP with women with substance use disorders in VA primary care.
Psychiatric and medical conditions that co-occur with substance use disorderFew women (2.8%) were treated in IOP at the VA. Among the women who did receive treatment, substantial clinical differences were found compared with men in IOP treatment. Women with substance use disorders were younger, more likely to have cocaine abuse or dependence disorders, and more likely to have extensive psychiatric and medical comorbidities than men with substance use disorders in the VA. Women in treatment were also found to be significantly different from women with substance use disorders not in treatment.
Stein 2004128Females in VA San Diego Healthcare System (VASDHS) primary care outpatient clinic.Females 219Observational;
To determine whether there is an association between sexual assault history and measures of somatic symptoms and illness attitudes in a sample of female VA primary care patients, a group in whom high rates of sexual trauma have been reported.
Traumatic exposure, including sexual assault, physical complaints, healthcare utilization, reported sick days, somatization symptoms, health anxiety.Sexual assault was associated with a significant increase in somatization scores, physical complaints across multiple symptom domains and health anxiety. Sexual assault was also a significant statistical predictor of having multiple sick days in the prior 6 months and of being a high utilizer of primary care visits in the prior 6 months.
Suris 2007189Female veterans enrolled in a medical or mental health clinic in the VA North Texas Health Care System and had at least one outpatient visit in past 5 yearsFemales
To explore how differences in various assault types impact health outcomes.
Civilian sexual assault (CSA) and military sexual assault (MSA) histories, psychiatric symptoms, alcohol abuse, physical health functioning, quality of lifeWomen veterans with CSA histories reported significantly poorer physical, psychiatric, and quality-of-life functioning compared to those without a history of sexual assault. Women veterans with an MSA history demonstrated additional negative consequences above and beyond the effects of CSA.
Suris 2004183Convenience sample of female veterans receiving medical and/or mental health treatment at the VA North Texas Healthcare System.Females
To examine (1) the differential impact of military, civilian adult, and childhood sexual assault on the likelihood of developing posttraumatic stress disorder (PTSD); and (2) the relationship of military sexual assault (MSA) to service utilization and health care costs among women who access services through Veterans Affairs (VA).
Sexual assault history, PTSD, psychiatric diagnosis, utilization of care and care costs.Compared with those without a history of sexual assault, female veterans were 9 times more likely to have PTSD if they had a history of MSA, 7 times more likely if they had childhood sexual assault (CSA) histories, and 5 times more likely if they had civilian sexual assault histories. An investigation of medical charts revealed that PTSD is diagnosed more often for women with a history of MSA than CSA. CSA was associated with a significant increase in health care utilization and cost for services, but there was no related increase in use or cost associated with MSA.
Teh 2008172Female and male VA patients in the National Psychosis Registry with a diagnosis of bipolar disorder, schizophrenia, schizoaffective disorder who completed the Large Health Survey of Veterans (LHSV) in FY 1999Females
To assess gender differences in health-related quality of life (HRQOL) in a national sample of veterans with serious mental illness (SMI)
Effect of gender on HRQOL (unadjusted and adjusted comparison), HRQOL of female and male veterans with SMI and female and male veterans without SMI, respectively (post hoc analysis to compare study results to normative data from previously published studies)The sample was 7.3% female, 75.7% white, and 83.8% unemployed. Mean±SD age was 54.3±12.2 years. After the analysis adjusted for sociodemographic characteristics, health status, and other variables, compared with male veterans, female veterans with serious mental illness had lower scores on the SF-36 physical component summary (indicating worse symptoms), were more likely to report that they were limited “a lot” in activities of daily living, and had more pain. However, female respondents were more likely to have a positive outlook on their health.
Vinokur 1999177Females in Air Force active duty reserve and guard forces.Females 525Observational;
To examine the effects of work and family stressors and conflicts on Air Force women’s mental health and functioning.
Job and parental stresses and work-family conflictsCompared to the representative community sample, Air Force women had higher levels of family stress, work-family work conflicts, and job distress (p<0.05 for each measure).
Vogt 2008145Female and male longitudinal cohort of active duty Marine recruits at Parris Island surveyed at two time pointsFemales
To examine the relationship between stress reactions and hardiness by gender during Marine Corp recruit training, and to examine how stress and hardiness differ based on social support.
Ratings of reactions to different stress factors, 3 domains of hardiness (i.e., control, commitment, and challenge); perceptions of social support, and negative emotions expressedWomen reported slightly higher levels of both negative affectivity (22.24 vs. 20.67) and stress reactions (21.93 vs. 19.52; p<.05 for each) at T1 compared with men. Women also reported slightly higher levels of stress reactions (19.01 vs. 16.34) and perceived social support (41.23 vs. 40.15; p<.05 for each) at T2 compared with men. Identified intercorrelations were similar across gender (e.g., negative affectivity had moderate relationships with both stress reactions and hardiness for both men and women, etc).
Although the negative impact of stress reactions on hardiness was strongest when social support was low for both genders, stress reactions predicted enhanced hardiness when social support was high for women only.
Vogt 2008143National sample of female and male Gulf War I veteransFemales 80
To identify differences in exposure to deployment stressors based on military status (i.e., active duty vs. National Guard/Reserve [NG/R] units) and to identify associations between deployment stressors and posttraumatic stress symptoms.
Deployment stressor scales (combat experiences, perceived threat, etc); predictors of posttraumatic stress symptomatology (PTSS)-Active duty reported more significant combat experiences than NG/R personnel. The NG/R personnel reported more concerns about family/relationship disruptions than active duty. Deployment risk factors were positively associated with PTSS and resilience factors were negatively associated with PTSS.
-The gender analysis indicated that perceived threat had greater PTSS associations for NG/R males compared to active duty males, while perceived threat had greater PTSS associations for active duty females compared to NG/R units.
Wallace 2006173Random sample of female and male veteran enrollees who had used VHA services within the prior three years or who had enrolled in VHA in anticipation of using services in the future.Total

Female/Male not listed
To study whether rural and urban disparities in health- related quality of life persist among veterans with common psychiatric disorders.
Health-related quality of life scores in rural and urban veterans with common psychiatric disorders.(1) All psychiatric disorders except anxiety disorders not related to PTSD were more prevalent in urban groups. (2) Rural veterans within mental illness cohorts had worse PCS and MCS scores, denoting worse physical and mental health-related quality of life. (3) In regression models, rural-urban disparities within psychiatric disorder cohorts persisted after sociodemographic factors were controlled. No findings were reported by gender.
Westrup 2005144Case study of 1 female veteran, who entered a residential program for treatment of PTSDFemales
Case study of the application of a non-traditional treatment (self defense training) for PTSD to treat the negative symptoms of PTSD.
Quality of life, personal safety and risk-taking1) Physical skills training was empowering for the patient.
2) Didactic portion was illustrative of social psycho-logical deficits that arise among women with trauma (e.g., not locking doors to car or house). Lessons targeted key skill deficits and faulty core beliefs (e.g., she brought trauma on herself).
3) Upon graduating from self-defense, she said she felt like she got her life back. The 6-month follow-up showed significant life changes: discarded weapons; bolstered home security; and beginning to socialize and travel again.
Wolfe 2005187Female and male US Marine Corp recruits at Parris IslandFemales
To study the impact of pre-military interpersonal trauma on attrition during USMC recruit training
Rates of interpersonal trauma by gender, time to attrition by gender, association of pre-military trauma and attritionAt least one type of trauma was reported by 47.5% of male recruits and 68.1% of female recruits (p<.01). Female recruits were more likely to be discharged compared with male recruits (HR 1.647, 95% CI 1.239 – 2.189). While retention rates for male recruits with and without a trauma history showed no difference, retention rates for female recruits with and with- out a trauma history significantly differed; females with an interpersonal trauma history were more likely to be discharged (HR 1.58, 95%CI 1.034 – 2.413).
Yaeger 2006165Female veteran convenience sample in 1 VAMC comprehensive women’s clinicFemales
To compare impact of military sexual trauma (MST) versus all other traumas on the rate of current PTSD diagnoses.
Rates of PTSDIn this group, 92% of women had at least 1 trauma; 41% had MST with or without other trauma; 90% had other trauma alone or in combination with MST. Moreover, 60% of those with MST and 43% of those with other trauma had PTSD. In logistic regression analyses, MST was a significant predictor of PTSD (OR 4.4, 95%CI 2.4, 8.2) and prior trauma was not (OR 1.3, 95%CI 0.63, 2.5).
Zeber 2007105Female and male veterans in National Psychoses Registry from June 1, 2000, through September 30, 2003, for all veterans diagnosed with schizophrenia and receiving healthcare through the Department of Veterans Affairs.Females
To assess the effect of the 200 Veterans Millennium Health Care Act, which raised pharmacy copayments from $2 to $7 for lower-priority patients, on medication refill decisions and health services utilization among vulnerable veterans with schizophrenia.
Total prescription fills, medical and psychotropic fills separately, outpatient visits, psychiatric admission, inpatient days among those admitted, and pharmacy costsTotal prescriptions and overall pharmacy costs leveled among veterans with copayments after the medication cost increase. However, psychiatric drug refills dropped substantially, nearly 25%. Although outpatient visits were unaffected, psychiatric admissions and total inpatient days increased slightly, particularly 10–20 months after the policy change.
Zivin 2007199Female and male patients from the VA’ s National Registry for Depression (NARDEP) linked to data from the VA Medicare Data Merge Initiative and the National Death Index.Females
Observational; To report clinical and demographic factors associated with suicide among depressed veterans in an attempt to determine what characteristics identified depressed veterans at high risk for suicide.Suicide and time until suicideIncreased suicide risks were observed among male, younger, and non-Hispanic White patients. Veterans without service-connected disabilities, with inpatient psychiatric hospitalizations in the year prior to their qualifying depression diagnosis, with comorbid substance use, and living in the southern or western United States were also at higher risk. Posttraumatic stress disorder (PTSD) with comorbid depression was associated with lower suicide rates, and younger depressed veterans with PTSD had a higher suicide rate than did older depressed veterans with PTSD. The relative risk ratio for men compared with women in the depressed VA population was somewhat smaller than that reported for the general population.


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