VA Women’s Mental Health Services VA Women’s Mental Health Services ResearchResearch

Paula P. Schnurr, Ph.DPaula P. Schnurr, Ph.D

VA National Center for PTSDVA National Center for PTSD

Dartmouth Medical SchoolDartmouth Medical School

HSR&D Support for Women’s HSR&D Support for Women’s Health ResearchHealth Research

• Special solicitation focused on WHR since Special solicitation focused on WHR since 19961996

• Aimed at explaining care and utilization by Aimed at explaining care and utilization by women Veterans and improving carewomen Veterans and improving care

• Includes Career Development Awards, Includes Career Development Awards, Center of Excellence funding, and a new Center of Excellence funding, and a new Women’s Health Research Women’s Health Research Consortium/Practice-Based Research Consortium/Practice-Based Research NetworkNetwork

Areas of HSR&D Research on Areas of HSR&D Research on Women VeteransWomen Veterans

• Delivery, organization, and systems of care for Delivery, organization, and systems of care for women veterans women veterans

• Gender-specific use of VA and non-VA careGender-specific use of VA and non-VA care• Gender-specific issues related to access and Gender-specific issues related to access and

barriers to care barriers to care • Quality of care Quality of care • Continuity, comprehensiveness, outcomes and Continuity, comprehensiveness, outcomes and

costs of carecosts of care• Other factors associated with health care for Other factors associated with health care for

women veterans, their special needs, and women veterans, their special needs, and potential disparitiespotential disparities

VA is A Natural Translational VA is A Natural Translational Research EnvironmentResearch Environment

CSP #494: Cognitive-Behavioral CSP #494: Cognitive-Behavioral Treatment of PTSD in WomenTreatment of PTSD in Women

The Science• 1st clinical trial of PTSD

treatment in female Veterans and Service Members

• 12 sites; 284 women

• Prolonged Exposure (PE) therapy shown to be effective (JAMA, 2007)

The Translation• National rollout of PE

implemented in 2008– 942 clinicians trained 7/1/10

• Infrastructure created to sustain implementation

• Research to enhance efficiency, outcome, and acceptability

HSR&D Women’s Health Research HSR&D Women’s Health Research Projects FY 2006-2009Projects FY 2006-2009

$10.9 millionmillion

34 projects34 projects– 26 mental health26 mental health– 5 organization & 5 organization &

quality of carequality of care– 3 other3 other

Why Focus on Mental Health in Why Focus on Mental Health in Women Veterans?Women Veterans?

VA Health Services VA Health Services Research has AnswersResearch has Answers

Women Who Use VA have Worse Mental Health Women Who Use VA have Worse Mental Health Relative to Women in the General PopulationRelative to Women in the General Population

0

20

40

60

80

100

PF RP BP GH RE MH VT SF

SF-36 Subscales

Me

an

Sc

ore

– Frayne et al., J Gen Intern Med 21:S40 (2006)

Veterans

General population

Mental Health Subscales

Among VA Users, Women are More Likely Among VA Users, Women are More Likely Than Men to have Mental Health ProblemsThan Men to have Mental Health Problems

0

5

10

15

20

25

Women Men

From Frayne, VA Women’s Health Evaluation Initiative. Percents are based on presence of at least 2 instances of mental health condition ICD-9 codes in VA outpatient administrative data in FY08; includes veteran patients only. 9

31% of women vs. 20% of men have a diagnosed mental health condition

Mental Health Problems Are Cross-Mental Health Problems Are Cross-Cutting: A Hidden VariableCutting: A Hidden Variable

• In women Veterans (male Veterans, civilians), In women Veterans (male Veterans, civilians), mental health problems are related to:mental health problems are related to:– More physical health problems and painMore physical health problems and pain– Greater service utilizationGreater service utilization– Lower psychosocial and occupational functioningLower psychosocial and occupational functioning– Poor self-care, e.g., smokingPoor self-care, e.g., smoking– Reduced quality of lifeReduced quality of life

Higher likelihood of mental health problems = Higher likelihood of mental health problems = More burdenMore burden

Even in Veterans with Mental Health Even in Veterans with Mental Health Problems, the Burden is Greater in Problems, the Burden is Greater in

WomenWomen

– Frayne, Kimerling, under review

FY06-07, OEF/OIF Veterans (N = 90, 558)

Military Sexual Trauma is Prevalent in Military Sexual Trauma is Prevalent in Women VeteransWomen Veterans

VA Users Screened for MST

Men Women

Veterans Screened FY 2005 (N = 3,045,000)

1.1% 21.8%

OEF/OIF Veterans Screened FY 2001-2007 (N = 126,729)

0.7% 15.1%

– Kimerling et al., 2007 & in press

Military Sexual Trauma Increases Risk Military Sexual Trauma Increases Risk of Comorbid Problemsof Comorbid Problems

All AORs significant at p < .05; adjusted for age, race, marital status, health insurance, service connection , prior VHA use, component, branch, and multiple deployments

– Kimerling et al., in press

Data from 126,729 OEF/OIF Veterans screened for sexual trauma in VA FYs 2001-2007

Odds Ratio for MST vs. no MST

And Where are We Headed?And Where are We Headed?

Mental HealthMental HealthAreas of HSR&DAreas of HSR&D∧∧Research on Research on

Women VeteransWomen Veterans

• Delivery, organization, and systems of care for Delivery, organization, and systems of care for women veterans women veterans

• Gender-specific use of VA and non-VA careGender-specific use of VA and non-VA care• Gender-specific issues related to access and Gender-specific issues related to access and

barriers to care barriers to care • Quality of care Quality of care • Continuity, comprehensiveness, outcomes and Continuity, comprehensiveness, outcomes and

costs of carecosts of care• Other factors associated with health care for Other factors associated with health care for

women veterans, their special needs, and women veterans, their special needs, and potential disparitiespotential disparities

CSP #579CSP #579: Long Term Health : Long Term Health Outcomes of Women’s Service Outcomes of Women’s Service

During the Vietnam WarDuring the Vietnam War

• Understand impact of Understand impact of wartime deployment on wartime deployment on physical and mental physical and mental health 40 years after the health 40 years after the Vietnam WarVietnam War

• 10,000+ women Vietnam 10,000+ women Vietnam era Veteransera Veterans

– K. Magruder, A. Kilbourne, & Kang, co-Chairs

Women Veterans Cohort StudyWomen Veterans Cohort Study

– C. Brandt, PI

Online Interventions for Female Online Interventions for Female OEF/OIF Reserve/National Guard War OEF/OIF Reserve/National Guard War

VetsVets

– A. Sadler, PI

Caring for Women Veterans StudyCaring for Women Veterans Study

• Evaluate a 30-minute Evaluate a 30-minute multi-media program for multi-media program for enhancing VA staff enhancing VA staff sensitivity to and sensitivity to and knowledge about women knowledge about women Veterans and their needsVeterans and their needs

• Extension of this project Extension of this project will be conducted will be conducted through new PBRNthrough new PBRN

– D. Vogt, PI

Other Examples of Current HSR&D Other Examples of Current HSR&D Projects on Women’s Mental HealthProjects on Women’s Mental Health

Bradley Bradley Urogenital Symptoms, Depression and PTSDUrogenital Symptoms, Depression and PTSD in OEF/OIF in OEF/OIF Women Veterans Women Veterans

Gerlock Gerlock Relationship and PTSD Study: Detection of Relationship and PTSD Study: Detection of Intimate Intimate Partner ViolencePartner Violence

Kline Kline Gender Differences in Gender Differences in Mental Health Treatment Needs Mental Health Treatment Needs and Service Useand Service Use

Lange Lange Pilot Study of Pilot Study of Re-IntegrationRe-Integration and Service Needs for and Service Needs for Women Veteran MothersWomen Veteran Mothers

ShipherdShipherd MST Effect on MST Effect on PTSD and Health BehaviorPTSD and Health Behavior: A Longitudinal : A Longitudinal Study of Study of MarinesMarines

Vogt Vogt StigmaStigma, Gender and Other , Gender and Other Barriers to VHA UseBarriers to VHA Use for for OIF/OEF VeteransOIF/OEF Veterans

Implications of Women’s Mental Implications of Women’s Mental Health Services ResearchHealth Services Research

• Prominence of mental health reflects need Prominence of mental health reflects need as well as cross-cutting effects of mental as well as cross-cutting effects of mental health on physical health and health health on physical health and health behaviorsbehaviors

• Women Veterans are Women Veterans are womenwomen– Generalizability to civilian womenGeneralizability to civilian women

• Women Veterans are Women Veterans are VeteransVeterans– Generalizability to male veterans tooGeneralizability to male veterans too