Clinical Complexity in Women Veterans: A Systematic Review of the Recent Evidence on Mental Health and Physical Health Comorbidities.

A recent evidence map focused on women veterans underscored the limited number of articles published on mental health comorbid with physical health conditions in this population. The quality of this small body of research has yet to be evaluated. The aim of this systematic review was to evaluate and synthesize research published between 2008 and 2015 and identified in the Women Veterans' Health Research Evidence Map as related to mental and physical health comorbidities among women veterans. Following PRISMA guidelines, 23 published studies were identified and 21 were included in the review. In general, significant associations between several mental health conditions (e.g., depression, posttraumatic stress disorder, substance use disorders) and physical health disorders (e.g., cardiovascular disease, diabetes, gastrointestinal disorders, hypertension, obesity, pain, and urinary symptoms) and health behaviors (e.g., preventative care and treatment adherence) were noted. The majority of studies were rated as low risk of bias, with selection and detection bias most frequently observed across studies. Additionally, gaps in the recent literature were observed, including the need for further investigation of the role of medical conditions in complicating mental health symptoms and care provision. Results underscore the importance of healthcare providers attending to women veterans' mental and physical health simultaneously and irrespective of setting. Further, while the Department of Veterans Affairs continues to make sizable gains in its focus on women veterans' health, continued research on several health domains is needed to ensure adequate understanding of the health needs of women veterans.

Facilitators and Barriers to Breastfeeding Among Veterans Using Veterans Affairs Maternity Care Benefits.

INTRODUCTION: U.S. veterans of childbearing age represent one of the fastest growing populations using Veterans Affairs (VA) health care. The VA does not provide obstetric care directly but pays for VA-enrolled veterans to obtain outside obstetric care. The VA also provides maternity care coordination (MCC) services, including lactation support. Breastfeeding benefits mothers and babies; however, previous research shows that veteran mothers quit exclusive breastfeeding earlier than the American Academy of Pediatrics and World Health Organization recommendation of 6 months. This study aimed to understand facilitators and barriers to breastfeeding among a cohort of veterans who used VA maternity care benefits. METHODS: Qualitative data from an open-ended question from a national sample of postpartum veterans using VA pregnancy benefits were coded using deductive and inductive content analysis within a matrix framework. Quantitative data were used to contextualize the responses. RESULTS: Four themes emerged from the data: (1) impacts on health of baby/mother; (2) the ability to breastfeed; (3) early postnatal experiences breastfeeding; and (4) cost/convenience. Among those who responded to the open-ended breastfeeding question (329/669), most participants (n = 316; 96%) attempted breastfeeding their current baby. Respondents who did not initiate breastfeeding or who discontinued breastfeeding earlier than planned cited diverse reasons. These included low milk supply, poor latch, nipple pain, mental health factors, and low confidence in their ability to continue breastfeeding. Participants cited the MCC program as a facilitator to breastfeeding, and non-VA hospital experiences were mentioned as barriers. CONCLUSION: Veterans in this cohort of 329 veterans who responded to an open-ended breastfeeding question wanted and attempted to breastfeed; however, barriers such as lactation challenges and unsupportive health care providers made it difficult to continue the practice. As the MCC program grows to include more lactation professionals, MCCs may address barriers such as lactation challenges and unsupportive non-VA health care providers. Further program development should focus on addressing these challenges prenatally.

PTSD, depression, and suicidality among survivors of childhood sexual trauma (CST), military sexual trauma (MST), and sexual revictimization (CST + MST).

OBJECTIVE: Research to date has not examined how childhood sexual trauma (CST) followed by sexual trauma during military service (MST) relates to posttraumatic stress disorder (PTSD), depression, and suicidality among women and men. Given the strong association between MST in particular, and these serious posttraumatic outcomes, the current study sought to address this gap. METHOD: The current study compared the mental health concerns of 268 treatment-seeking veterans who were survivors of CST, MST, or both (CST + MST). We hypothesized that MST would be associated with greater severity of symptoms compared with CST and that those who experienced sexual revictimization (CST + MST) would report more severe symptoms than veterans who experienced CST or MST alone. RESULTS: Veteran men presented with significantly higher suicidality but not higher PTSD or depression scores than women. Controlling for gender, MST survivors had significantly higher PTSD and depression symptom severity scores, but not suicidality, than CST survivors. PTSD, depression, and suicidality scores were significantly higher for the CST + MST group than for CST only survivors, but did not significantly differ from survivors of MST alone. CONCLUSION: Findings support the more severe clinical impact of CST + MST-specific sexual revictimization compared with CST-only among military men and women, but also suggest that MST alone can have negative consequences similar to revictimization. While results point to the need to consider context and trauma history in future trauma research and clinical applications, they should be interpreted in light of our sample demographics, which were representative of the southwest U.S. veteran population. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Perinatal Depression Treatment Guidelines for Obstetric Providers.

Perinatal depression is the occurrence of depressive symptoms during the antenatal or postnatal period with an annual incidence of 10% to 20%. The consequences of untreated perinatal depression are significant and include negative impacts on maternal health, pregnancy outcomes, and maternal-infant outcomes. The purpose of this article is to provide perinatal pharmacologic and psychological treatment information to help first-line providers more confidently manage depression in the perinatal period. Treatment strategies including medication management using risk versus risk conversations, psychotherapy, and colocated perinatal mental health clinics are discussed.

Use of a Benchmark Tracking Assessment to Support Expansion of Buprenorphine for Treatment of Opioid Use Disorder in Primary Care.

INTRODUCTION: Barriers to the expansion of opioid use disorder (OUD) treatment in primary care using buprenorphine are well documented. Providers require support along a continuum. A systematic tracking framework to enhance provider progress along this continuum is lacking. METHODS: We developed a benchmark tracking assessment (BTA) as part of data collection in a 5-year study to examine the impact of provider participation in an online intervention to support expansion of buprenorphine treatment for OUD in rural primary care. Providers were contacted via phone every 3 months for up to 2 years to track their advancement along the 5 identified key benchmarks and were offered support for any barriers encountered. RESULTS: Forty-one providers enrolled in the study. Almost half (49%) did not experience a barrier that prevented them from accomplishing their next benchmark. Of the remaining 51% of providers, the majority (75%) experienced barriers early in the training and licensure phases, with most citing lack of time as the main reason. CONCLUSION: The BTA offers a feasible approach to identifying challenges along the training to prescription continuum and facilitated targeted support to address barriers. This framework has the potential, with locally contextual adaptations, to guide medication-assisted treatment implementation and training efforts.

The protective role of reasons for living on suicidal cognitions for military affiliated individuals with a positive PTSD screen in primary care settings.

BACKGROUND: Identifying and enhancing protective beliefs is essential in reducing suicide risk among military-affiliated individuals. The goal of this study was to examine if specific reasons for living impact the relationship between PTSD and suicidal cognitions among military-affiliated individuals in primary care settings. METHODS: Participants included 2,685 U.S. military personnel and their adult beneficiaries recruited from primary care clinics. Participants completed the Primary Care Posttraumatic Stress Disorder Screen, Suicide Cognitions Scale, and Brief Reasons for Living Inventory. RESULTS: Responsibility to family and survival and coping beliefs-were related to suicidal cognitions with higher levels associated with less suicidal cognitions and a weaker relationship between PTSD and suicidal cognitions. By contrast, fear of suicide and fear of social disapproval were associated with more suicidal cognitions, and the link between positive PTSD screen and suicidal cognitions was stronger for individuals with higher levels of fear of social disapproval. Moral objection did not predict suicidal cognitions and did not moderate the relationship between PTSD and suicidal cognitions. LIMITATIONS: The limitations of the study include that measures were done in primary care and brief screeners were often used. Additionally, the study is cross-sectional in nature, whereas some of the symptoms and outcome variables likely fluctuate over time. CONCLUSIONS: Findings suggest not all reasons for living are not equally influential and, among military-affiliated individuals with a positive PTSD screen, bolstering reasons for living related to responsibility to family and survival and coping skills could be particularly impactful in reducing suicide cognitions.

Relationships among adverse childhood experiences, posttraumatic stress disorder symptom clusters, and health in women veterans.

Adverse childhood experiences (ACEs) increase risk for negative health outcomes. The goal of this study was to examine the relationships among cumulative ACEs, ACEs type, posttraumatic stress disorder (PTSD) symptoms, PTSD symptom clusters, and physical health symptoms in a sample of women veterans (N = 76). Bivariate correlations were used to determine which ACE domains were associated with PTSD and physical health symptoms. Follow-up linear regressions indicated cumulative ACEs were significantly associated with total PTSD symptoms. Cumulative ACEs were also significantly associated with the avoidance and hyperarousal symptom clusters, but not the re-experiencing symptom cluster. Total PTSD symptoms were significantly related to physical health symptoms. Of the three symptom clusters, only hyperarousal was significantly associated with physical health symptoms. Cross-sectional mediation analyses indicated the total and direct effects of ACEs on physical health were not significant. However, the indirect effect through PTSD was significant (b = 0.46, [95% CI: 0.02, 0.91]), as well as through the avoidance (b = 0.47, [95% CI: 0.06, 0.90]), and hyperarousal symptom clusters (b = 0.56, [95% CI: 0.11, 1.04]). This study highlights the potential impact of ACEs on PTSD symptoms and physical health and suggests that hyperarousal symptoms of PTSD, may play a potential role in the development of physical health problems.

Suicidal Ideation in Pregnant and Postpartum Women Veterans: An Initial Clinical Needs Assessment.

INTRODUCTION: Pregnancy and postpartum, or the perinatal period, are times when women are particularly vulnerable to mental health concerns, including suicidal ideation. Risk factors for suicidal ideation during this period of a woman's life are depression and exposure to trauma, the latter of which may occur during military operations. The number of women veterans in the United States continues to rise, as does their use of maternity benefits. In this pilot study, we examined the feasibility of recruiting pregnant veterans for longitudinal research. We hypothesized that hopelessness and depressive symptoms would be related to suicidal ideation during the perinatal period, and we investigated a possible relationship between post-traumatic stress symptoms (PTSS) and suicidal ideation. MATERIALS AND METHODS: Using the designated Veterans Affairs (VA) maternity care coordinator's census, we contacted pregnant women veterans for assessment during the 3rd trimester of pregnancy and 6 weeks postpartum at the San Diego VA. Between September 2017 and October 2018, 28 women volunteers completed the following measures: the Columbia-Suicide Severity Rating Scale (C-SSRS); the Beck Hopelessness Scale (BHS); the Edinburgh Postnatal Depression Scale (EPDS); and the PTSD Checklist for DSM-5 (PCL-5). We used correlational analyses and descriptive statistics to determine associations among the measures. RESULTS: As gathered from the C-SSRS, over 30% of the veteran women had past lifetime suicide attempts, and over 10% of the veterans had suicidal ideation in the perinatal period. Both depression and PTSS rates neared 30% during pregnancy and postpartum. Hopelessness and depressive symptoms were positively correlated at both time points. While the intensity of lifetime suicidal ideation was correlated with postpartum depressive symptoms, there was no correlation with current suicidal ideation and depressive symptoms. PTSS correlated with both depressive symptoms and hopelessness, but not suicidal ideation, at both time points. There was no correlation between hopelessness and suicidal ideation during the perinatal period in this cohort. CONCLUSIONS: It is important to understand the mental health needs of perinatal veterans given their vulnerability to develop mental health concerns, including suicidal ideation. The unpredicted pattern of correlations determined in this study implies the need for multifaceted measures for safety-related mental health assessment of perinatal veterans, including assessment for PTSS. Strengths of this study include its longitudinal assessment and a sampling from a general population of veterans. Limitations include small sample size, a single gestational time point, and loss of participants who did not return for their postpartum assessment. We demonstrated the feasibility of longitudinal research with pregnant and postpartum veterans, but additional assessment points during the perinatal period could help identify critical times for mental health intervention in this population.

Targeting hyperarousal: Mantram Repetition Program for PTSD in US veterans.

Background: Hyperarousal appears to play an important role in the development and maintenance of posttraumatic stress disorder (PTSD) symptoms, but current evidence-based treatments appear to address this symptom type less effectively than the other symptom clusters. The Mantram Repetition Program (MRP) is a meditation-based intervention that has previously been shown to improve symptoms of posttraumatic stress disorder (PTSD) and may be especially helpful for hyperarousal. If MRP is an effective tool for decreasing this often treatment-resistant symptom cluster, it may become an important clinical tool. Objective: The goal of this secondary analysis was to examine the effect of the MRP on hyperarousal and other PTSD symptom clusters and to examine hyperarousal as a mediator of treatment response. Method: Secondary analyses were conducted on data from a randomized controlled trial in which Veterans with PTSD (n = 173) were assigned to the MRP or a non-specific psychotherapy control and assessed pre-treatment, post-treatment and 8 weeks after treatment completion. The impact of the interventions on PTSD symptom clusters was examined, and time-lagged hierarchical linear modelling was applied to examine alternative mediation models. Results: All PTSD symptom clusters improved in both treatments. MRP led to greater reductions in hyperarousal at post-treatment (Hedge's g = 0.57) and follow-up (Hedge's g = 0.52), and in numbing at post-treatment (Hedge's g = 0.47). Hyperarousal mediated reductions in the composite of the other PTSD symptom clusters. Although the reverse model was significant as well, the effect was weaker in this direction. Conclusion: Interventions focused on the management of hyperarousal may play an important role in recovery from PTSD. The MRP appears efficacious in reducing hyperarousal, and thereby impacting other PTSD symptom clusters, as one pathway to facilitating recovery.

Antecedentes: La hipervigilancia parece desempeñar un papel importante tanto en el desarrollo como en la mantención de los síntomas del trastorno de estrés postraumático (TEPT), pero los tratamientos basados en la evidencia actuales parecen abordar esta sintomatología de una manera menos efectiva que otras constelaciones de síntomas. El Programa de Repetición de Mantras (MRP por sus siglas en inglés) es una intervención basada en la meditación que previamente ha demostrado que puede mejorar los síntomas del TEPT y que pudiese ser beneficiosa específicamente en la hipervigilancia Si el MRP fuese una técnica efectiva para disminuir este síntoma que frecuentemente es resistente al tratamiento, se podría convertir en una herramienta clínica importante.Objetivo: El objetivo de este análisis secundario fue el evaluar el efecto del MRP sobre la hipervigilancia y otras constelaciones sintomáticas del TEPT, y el de evaluar cómo la hipervigilancia media la respuesta al tratamiento.Método: Se realizaron análisis secundarios sobre la base de datos de un ensayo clínico controlado aleatorizado en el cual un grupo de veteranos con TEPT (n = 173) fueron asignados al programa MRP o a un grupo control de psicoterapia inespecífica. Se evaluaron antes del tratamiento, inmediatamente luego del tratamiento, y a las ocho semanas posteriores de concluir el tratamiento. Se evaluó el impacto de las intervenciones sobre las constelaciones de síntomas del TEPT, y se aplicó un modelo linear jerárquico de temporalidad retrasada para evaluar modelos alternativos de mediación.Resultados: Todas las constelaciones sintomáticas del TEPT mejoraron con ambos tratamientos. El MRP condujo a mayores reducciones en la hipervigilancia inmediatamente luego del tratamiento (g de Hedge = 0,57) y en el seguimiento (g de Hedge = 0,52), así como en la insensibilidad inmediatamente luego del tratamiento (g de Hedge = 0,47). La hipervigilancia medió las reducciones en la integración de otras constelaciones sintomáticas del TEPT. A pesar de que el modelo de regresión también fue significativo, el efecto fue más débil en esta dirección.Conclusión: Las intervenciones enfocadas en el manejo de la hipervigilancia podrían desempeñar un papel importante en la recuperación del TEPT. El MRP impresiona ser eficaz en reducir la hipervigilancia, generando de esta manera un impacto sobre otras constelaciones sintomáticas del TEPT, constituyéndose en un camino para facilitar la recuperación.

Screening for History of Childhood Abuse: Beliefs, Practice Patterns, and Barriers Among Obstetrician-Gynecologists.

BACKGROUND: A history of childhood abuse is strongly linked to adult health problems. Obstetrician-gynecologists will undoubtedly treat abuse survivors during their careers, and a number of patient presenting problems may be related to a history of childhood abuse (e.g., chronic pelvic pain, sexual dysfunction, mental health disorders, obesity, and chronic diseases). Knowledge of abuse history may assist with treatment planning and the delivery of trauma-informed care. The current study sought to explore obstetrician-gynecologists' training, knowledge, beliefs, practice patterns, and barriers around screening for history of childhood abuse in their adult patients. METHODS: Eight hundred Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists were sent an electronic survey; 332 viewed recruitment emails. Data were analyzed with SPSS 24.0, including descriptive statistics, χ2, and t tests. RESULTS: One-hundred forty-five physicians completed the survey. The majority of responding providers believe that assessment of abuse history is important and relevant to patient care, yet few reported screening regularly. Most did not have formal training in screening for childhood abuse or its effects, although those who completed their training more recently were more likely to report training in these areas, as well as more likely to screen regularly. The majority of respondents noted they were not confident to screen. Barriers to screening were identified. CONCLUSIONS: Greater education and training about screening for childhood abuse history and the effects of childhood abuse are needed. The integration of mental health providers into practice is one method that may increase screening rates.

Ethnicity and Sexual Attitudes Affect Women's Judgments of Sexual Victimization Risk.

This study evaluated the effects of ethnicity, sexual attitudes, and sexual victimization history on women's judgments of sexual victimization risk in a set of dating and social scenarios. An ethnically diverse sample of undergraduate women ( n = 408) were asked to rate how risky the situations were in terms of having an unwanted sexual experience. American Indian women rated the situations as more risky than did non-Hispanic White or Hispanic women. In addition, participants with more positive attitudes toward a range of sexual experiences rated the situations as less risky than did women with less positive attitudes. Possible implications are discussed.