Study adaptation, design, and methods of a web-based PTSD intervention for women Veterans

Adaptation of an evidence-based, preventive intervention to promote mental health in Hispanic adolescents: eHealth Familias Unidas Mental Health

Youth internalizing symptoms (i.e., depression and anxiety), suicide ideation and attempts have been rising in recent years, including among Hispanics. Disparities in mental healthcare are concerning and require intervention, ideally prevention or early intervention. Familias Unidas is a culturally-syntonic, family-centered intervention effective in reducing youth drug use and sexual risk, with evidence of unanticipated effects on internalizing symptoms. This paper describes the systematic process used to adapt the eHealth version of the Familias Unidas intervention to more directly address internalizing symptoms and suicide risk in preparation for an effectiveness-implementation hybrid trial for youth with elevated internalizing symptoms, a history of suicide ideation/attempts, or poor parent-youth communication. The resulting eHealth Familias Unidas Mental Health intervention is described. Guided by a 4-phase framework, the steps in the adaptation process involved: assessment of the community and intervention delivery setting (pediatric primary care clinics); integration of previous intervention research, including intervention mechanisms of action; and expert and community consultation via focus groups. Focus group analyses showed that youth and parents perceived that the intervention was helpful. Their feedback was categorized into themes that were used to directly target mental health by addressing technology use, parent mental health, and social support. Effective and scalable preventive interventions are needed to address mental health disparities. The systematic adaptation process described in this paper is an efficient approach to expanding interventions while maintaining known, empirical and theoretical mechanisms of action. Findings from the ongoing effectiveness-implementation trial will be critical.

Military Sexual Trauma As a Risk Factor for Treatment Non-Response from an Online, Self-Management Posttraumatic Stress Disorder Treatment for Women Veterans

Women veterans are exposed to high rates of trauma, including military sexual trauma (MST), and face unique barriers to posttraumatic stress disorder (PTSD) treatment. Telehealth interventions that are tailored to women veterans' unique lived experiences may improve treatment engagement and outcomes. It is important to ascertain how beneficial new telehealth interventions are in the context of different patient characteristics and trauma types, particularly for lower-intensity telehealth interventions (e.g., web-based programs or apps). This secondary analysis of a randomized clinical trial conducted in a sample of 102 women veterans examines predictors of treatment response to a self-management, telehealth intervention for PTSD: Delivery of Self Training and Education for Stressful Situations-Women Veterans (DESTRESS-WV). In the trial, women veterans with PTSD received either an online cognitive behavioral intervention with phone coaching, or phone monitoring alone. We examined associations between baseline patient characteristics (demographics, trauma types, and clinical symptoms) and treatment outcome at post-treatment, 3 months, and 6 months, focusing on the association between treatment outcome and MST. Our primary outcomes were changes in PTSD (PTSD Symptom Checklist, Version 5, PCL-5) and depression (8-item Patient Health Questionnaire, PHQ-8) in the full sample, adjusting for treatment condition. Women veterans who identified MST as the primary trauma for which they were seeking PTSD treatment experienced a nearly nine-point lesser improvement on the PCL-5 than those seeking PTSD treatment for other trauma types (e.g., childhood abuse, combat trauma; p = .0073). Similar patterns were found for depression symptoms. To our knowledge, this is the first study to examine the association between trauma type and treatment outcomes within the context of a self-management, telehealth treatment for PTSD. While the study was not powered to examine differential treatment response for patient subgroups, our exploratory findings suggest that gaps remain in providing effective PTSD care for women veterans who experienced MST.Trial registration: The trial and analysis plan were preregistered in ClinicalTrials.gov (Identifier: NCT02917447).

Exploring Interactions Between Traumatic Brain Injury History and Gender on Medical Comorbidities in Military Veterans: An Epidemiological Analysis in the VA Million Veteran Program

Epidemiological studies of medical comorbidities and possible gender differences associated with traumatic brain injury (TBI) are limited, especially among military veterans. The purpose of this study was to examine relationships between TBI history and a wide range of medical conditions in a large, national sample of veterans, and to explore interactions with gender. Participants of this cross-sectional epidemiological study included 491,604 veterans (9.9% TBI cases; 8.3% women) who enrolled in the VA Million Veteran Program (MVP). Outcomes of interest were medical comorbidities (i.e., neurological, mental health, circulatory, and other medical conditions) assessed using the MVP Baseline Survey, a self-report questionnaire. Logistic regression models adjusting for age and gender showed that veterans with TBI history consistently had significantly higher rates of medical comorbidities than controls, with the greatest differences observed across mental health (odds ratios [ORs] = 2.10-3.61) and neurological (ORs = 1.57-6.08) conditions. Similar patterns were found when evaluating men and women separately. Additionally, significant TBI-by-gender interactions were observed, particularly for mental health and neurological comorbidities, such that men with a history of TBI had greater odds of having several of these conditions than women with a history of TBI. These findings highlight the array of medical comorbidities experienced by veterans with a history of TBI, and illustrate that clinical outcomes differ for men and women with TBI history. Although these results are clinically informative, more research is needed to better understand the role of gender on health conditions in the context of TBI and how gender interacts with other social and cultural factors to influence clinical trajectories following TBI. Ultimately, understanding the biological, psychological, and social mechanisms underlying these comorbidities may help with tailoring TBI treatment by gender and improve quality of life for veterans with TBI history.

Applying Rapid Qualitative Analysis for Health Equity: Lessons Learned Using "EARS" With Latino Communities

Qualitative research amplifies the voices of marginalized communities and thus plays a critical role in shaping our understanding of health inequities and their social determinants. Traditional qualitative approaches, such as grounded theory or thematic analysis, require extensive training and are time- and labor-intensive; as such, they may not be adequately suited to address healthy equity issues that require a swift response. Rapid qualitative analysis (RQA) is an action-oriented approach to qualitative data analysis that may be used when findings are needed to quickly inform practice. RQA capitalizes on using a team to summarize key points from qualitative data into matrices to explore relevant themes efficiently and systematically. In this paper, we provide case examples from our work applying RQA to health equity research with Latino communities to address community needs, such as responses to public health emergencies and the development of service delivery and technology interventions for infectious and chronic diseases. We draw from our collective experiences to share lessons learned and provide the following specific recommendations ("EARS") to researchers interested in applying RQA for health equity research: (1) Employ RQA to address rapidly evolving, urgent, health equity challenges; (2) Assure quality and rigor throughout the RQA process; (3) Respond to barriers and problem-solve as needed; and (4) Strengthen community relationships before, during, and after using RQA. Overall, we advocate for the use of RQA to promote health equity due to its ability to integrate the vital perspectives of marginalized communities and efficiently respond to their needs.

Interventions for Women Veterans with Mental Health Care Needs: Findings from a Scoping Review

Experts have prioritized research on women veterans' mental health and the delivery of gender-sensitive care. The purpose of this study was to conduct a scoping review of the literature to summarize interventions for women veterans with mental health care needs designed in the Department of Veterans Affairs (VA). We identified 1,073 articles; eight were eligible for full review and represented seven unique interventions. Four studies focused on individual-level interventions; three studies focused on interpersonal-level interventions. Some attributes of gender-sensitive care included modifying the treatment environment and offering same gender clinicians. In designing interventions, clinicians and researchers can: (a) create interprofessional teams which include nurses, (b) use participatory methods to improve study designs, (c) assess participants' barriers to care prior to designing interventions, (d) incorporate and evaluate attributes of gender-sensitive care, and (e) utilize and clearly delineate how theory guides research. With improved intervention research, clinicians and researchers can support women veterans with mental health care needs.

Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults

BACKGROUND

Therapist-delivered trauma-focused psychological therapies are effective for post-traumatic stress disorder (PTSD) and have become the accepted first-line treatments. Despite the established evidence-base for these therapies, they are not always widely available or accessible. Many barriers limit treatment uptake, such as the number of qualified therapists available to deliver the interventions; cost; and compliance issues, such as time off work, childcare, and transportation, associated with the need to attend weekly appointments. Delivering Internet-based cognitive and behavioural therapy (I-C/BT) is an effective and acceptable alternative to therapist-delivered treatments for anxiety and depression.

OBJECTIVES

To assess the effects of I-C/BT for PTSD in adults.

SEARCH METHODS

We searched MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials to June 2020. We also searched online clinical trial registries and reference lists of included studies and contacted the authors of included studies and other researchers in the field to identify additional and ongoing studies.

SELECTION CRITERIA

We searched for RCTs of I-C/BT compared to face-to-face or Internet-based psychological treatment, psychoeducation, wait list, or care as usual. We included studies of adults (aged over 16 years), in which at least 70% of the participants met the diagnostic criteria for PTSD, according to the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed abstracts, extracted data, and entered data into Review Manager 5. The primary outcomes were severity of PTSD symptoms and dropouts. Secondary outcomes included diagnosis of PTSD after treatment, severity of depressive and anxiety symptoms, cost-effectiveness, adverse events, treatment acceptability, and quality of life. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data using a fixed-effect meta-analysis, except where heterogeneity was present, in which case we used a random-effects model. We independently assessed the included studies for risk of bias and we evaluated the certainty of available evidence using the GRADE approach; we discussed any conflicts with at least one other review author, with the aim of reaching a unanimous decision.

MAIN RESULTS

We included 13 studies with 808 participants. Ten studies compared I-C/BT delivered with therapist guidance to a wait list control. Two studies compared guided I-C/BT with I-non-C/BT. One study compared guided I-C/BT with face-to-face non-C/BT. There was substantial heterogeneity among the included studies. I-C/BT compared with face-to-face non-CBT Very low-certainty evidence based on one small study suggested face-to-face non-CBT may be more effective than I-C/BT at reducing PTSD symptoms post-treatment (MD 10.90, 95% CI 6.57 to 15.23; studies = 1, participants = 40). There may be no evidence of a difference in dropout rates between treatments (RR 2.49, 95% CI 0.91 to 6.77; studies = 1, participants = 40; very low-certainty evidence). The study did not measure diagnosis of PTSD, severity of depressive or anxiety symptoms, cost-effectiveness, or adverse events. I-C/BT compared with wait list Very low-certainty evidence showed that, compared with wait list, I-C/BT may be associated with a clinically important reduction in PTSD post-treatment (SMD -0.61, 95% CI -0.93 to -0.29; studies = 10, participants = 608). There may be no evidence of a difference in dropout rates between the I-C/BT and wait list groups (RR 1.25, 95% CI 0.97 to 1.60; studies = 9, participants = 634; low-certainty evidence). I-C/BT may be no more effective than wait list at reducing the risk of a diagnosis of PTSD after treatment (RR 0.53, 95% CI 0.28 to 1.00; studies = 1, participants = 62; very low-certainty evidence). I-C/BT may be associated with a clinically important reduction in symptoms of depression post-treatment (SMD -0.51, 95% CI -0.97 to -0.06; studies = 7, participants = 473; very low-certainty evidence). Very low-certainty evidence also suggested that I-C/BT may be associated with a clinically important reduction in symptoms of anxiety post-treatment (SMD -0.61, 95% CI -0.89 to -0.33; studies = 5, participants = 345). There were no data regarding cost-effectiveness. Data regarding adverse events were uncertain, as only one study reported an absence of adverse events. I-C/BT compared with I-non-C/BT There may be no evidence of a difference in PTSD symptoms post-treatment between the I-C/BT and I-non-C/BT groups (SMD -0.08, 95% CI -0.52 to 0.35; studies = 2, participants = 82; very low-certainty evidence). There may be no evidence of a difference between dropout rates from the I-C/BT and I-non-C/BT groups (RR 2.14, 95% CI 0.97 to 4.73; studies = 2, participants = 132; I² = 0%; very low-certainty evidence). Two studies found no evidence of a difference in post-treatment depressive symptoms between the I-C/BT and I-non-C/BT groups (SMD -0.12, 95% CI -0.78 to 0.54; studies = 2, participants = 84; very low-certainty evidence). Two studies found no evidence of a difference in post-treatment symptoms of anxiety between the I-C/BT and I-non-C/BT groups (SMD 0.08, 95% CI -0.78 to 0.95; studies = 2, participants = 74; very low-certainty evidence). There were no data regarding cost-effectiveness. Data regarding adverse effects were uncertain, as it was not discernible whether adverse effects reported were attributable to the intervention.

AUTHORS' CONCLUSIONS

While the review found some beneficial effects of I-C/BT for PTSD, the certainty of the evidence was very low due to the small number of included trials. This review update found many planned and ongoing studies, which is encouraging since further work is required to establish non-inferiority to current first-line interventions, explore mechanisms of change, establish optimal levels of guidance, explore cost-effectiveness, measure adverse events, and determine predictors of efficacy and dropout.

A randomized trial of an online, coach-assisted self-management PTSD intervention tailored for women veterans

OBJECTIVE

Scalable, efficiently delivered treatments are needed to address the needs of women Veterans with PTSD. This randomized clinical trial compared an online, coach-assisted cognitive behavioral intervention tailored for women Veterans with PTSD to phone monitoring only.

METHOD

Women Veterans who met diagnostic criteria for PTSD were randomized to an 8-week web-based intervention, called DElivery of Self TRaining and Education for Stressful Situations (DESTRESS)-Women Veterans version (WV), or to phone monitoring only (N = 102). DESTRESS-WV consisted of online sessions and 15-min weekly phone calls from a study coach. Phone monitoring included 15-min weekly phone calls from a study coach to offer general support. PTSD symptom severity (PTSD Symptom-Checklist-Version 5 [PCL-5]) was evaluated pre and posttreatment, and at 3 and 6 months posttreatment.

RESULTS

More participants completed phone monitoring than DESTRESS-WV (96% vs. 76%, p = 0.01), although treatment satisfaction was significantly greater in the DESTRESS-WV condition. We failed to confirm the superiority of DESTRESS-WV in intent-to-treat slope changes in PTSD symptom severity. Both treatments were associated with significant reductions in PTSD symptom severity over time. However, post hoc analyses of treatment completers and of those with baseline PCL ≥ 33 revealed that the DESTRESS-WV group had greater improvement in PTSD symptom severity relative to phone monitoring with significant differences at the 3-month follow-up assessment.

CONCLUSIONS

Both DESTRESS-WV and phone monitoring resulted in significant improvements in women Veterans' PTSD symptoms. DESTRESS-WV may be an appropriate care model for women Veterans who can engage in the demands of the treatment and have higher baseline symptoms. Future research should explore characteristics of and the methods of reliably identifying women Veterans who are most likely to benefit. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Differences in functional and structural social support among female and male veterans and civilians

PURPOSE

Social support is an important correlate of health behaviors and outcomes. Studies suggest that veterans have lower social support than civilians, but interpretation is hindered by methodological limitations. Furthermore, little is known about how sex influences veteran-civilian differences. Therefore, we examined veteran-civilian differences in several dimensions of social support and whether differences varied by sex.

METHODS

We performed a cross-sectional analysis of the 2012-2013 National Epidemiologic Survey of Alcohol and Related Conditions-III, a nationally representative sample of 34,331 respondents (male veterans = 2569; female veterans = 356). We examined veteran-civilian differences in functional and structural social support using linear regression and variation by sex with interactions. We adjusted for socio-demographics, childhood experiences, and physical and mental health.

RESULTS

Compared to civilians, veterans had lower social network diversity scores (difference [diff] = - 0.13, 95% confidence interval [CI] - 0.23, - 0.03). Among women but not men, veterans had smaller social network size (diff = - 2.27, 95% CI - 3.81, - 0.73) than civilians, attributable to differences in religious groups, volunteers, and coworkers. Among men, veterans had lower social network diversity scores than civilians (diff = - 0.13, 95% CI - 0.23, - 0.03); while among women, the difference was similar but did not reach statistical significance (diff = - 0.13, 95% CI - 0.23, 0.09). There was limited evidence of functional social support differences.

CONCLUSION

After accounting for factors that influence military entry and social support, veterans reported significantly lower structural social support, which may be attributable to reintegration challenges and geographic mobility. Findings suggest that veterans could benefit from programs to enhance structural social support and improve health outcomes, with female veterans potentially in greatest need.

Digitalizing a Brief Intervention to Reduce Intrusive Memories of Psychological Trauma: Qualitative Interview Study

BACKGROUND

The COVID-19 pandemic has escalated the global need for remotely delivered and scalable interventions after psychological trauma. A brief intervention involving a computer game as an imagery-competing task has shown promising results for reducing the number of intrusive memories of trauma-one of the core clinical symptoms of posttraumatic stress disorder. To date, the intervention has only been delivered face-to-face. To be tested and implemented on a wider scale, digital adaptation for remote delivery is crucial. An important first step is to develop digitalized intervention materials in a systematic way based on feedback from clinicians, researchers, and students in preparation for pilot testing with target users.

OBJECTIVE

The first aim of this study is to obtain and analyze qualitative feedback on digital intervention materials, namely two animated videos and two quizzes that explain the target clinical symptoms and provide intervention instructions. The second aim is to refine the digitalized materials based on this feedback.

METHODS

We conducted semistructured interviews with 12 participants who had delivered or had knowledge of the intervention when delivered face-to-face. We obtained in-depth feedback on the perceived feasibility of using the digitalized materials and suggestions for improvements. Interviews were assessed using qualitative content analysis, and suggested improvements were evaluated for implementation using a systematic method of prioritization.

RESULTS

A total of three overarching themes were identified from the data. First, participants were highly positive about the potential benefits of using these digital materials for remote delivery, reporting that the videos effectively conveyed key concepts of the symptom and its treatment. Second, some modifications to the materials were suggested for improving clarity. On the basis of this feedback, we made nine specific changes. Finally, participants raised some key challenges for remote delivery, mainly in overcoming the lack of real-time communication during the intervention.

CONCLUSIONS

Clinicians, researchers, and clinical psychology students were overall confident in the use of digitalized materials to remotely deliver a brief intervention to reduce intrusive memories of trauma. Guided by participant feedback, we identified and implemented changes to refine the intervention materials. This study lays the groundwork for the next step: pilot testing remote delivery of the full intervention to trauma survivors.

Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults

BACKGROUND

Therapist-delivered trauma-focused psychological therapies are an effective treatment for post-traumatic stress disorder (PTSD). These have become the accepted first-line treatments for the disorder. Despite the established evidence-base for these therapies, they are not always widely available or accessible. Many barriers limit treatment uptake, such as the limited number of qualified therapists to deliver the interventions, cost, and compliance issues, such as time off work, childcare, and transportation, associated with the need to attend weekly appointments. Delivering cognitive behavioural therapy (CBT) on the Internet is an effective and acceptable alternative to therapist-delivered treatments for anxiety and depression. However, fewer Internet-based therapies have been developed and evaluated for PTSD, and uncertainty surrounds the efficacy of Internet-based cognitive and behavioural therapy (I-C/BT) for PTSD.

OBJECTIVES

To assess the effects of I-C/BT for PTSD in adults.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group's Specialised Register (CCMDCTR) to June 2016 and identified four studies meeting the inclusion criteria. The CCMDCTR includes relevant randomised controlled trials (RCT) from MEDLINE, Embase, and PsycINFO. We also searched online clinical trial registries and reference lists of included studies, and contacted researchers in the field to identify additional and ongoing studies. We ran an update search on 1 March 2018, and identified four additional completed studies, which we added to the analyses along with two that were previously awaiting classification.

SELECTION CRITERIA

We searched for RCTs of I-C/BT compared to face-to-face or Internet-based psychological treatment, psychoeducation, wait list or care as usual. We included studies of adults (aged over 16 years or over), in which at least 70% of the participants met the diagnostic criteria for PTSD, according to the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD).

DATA COLLECTION AND ANALYSIS

We entered data into Review Manager 5 software. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data with a fixed-effect meta-analysis, except where heterogeneity was present, in which case we used a random-effects model. Two review authors independently assessed the included studies for risk of bias; any conflicts were discussed with a third author, with the aim of reaching a unanimous decision.

MAIN RESULTS

We included 10 studies with 720 participants in the review. Eight of the studies compared I-C/BT delivered with therapist guidance to a wait list control. Two studies compared guided I-C/BT with I-non-C/BT. There was considerable heterogeneity among the included studies.Very low-quality evidence showed that, compared with wait list, I-C/BT may be associated with a clinically important reduction in PTSD post-treatment (SMD -0.60, 95% CI -0.97 to -0.24; studies = 8, participants = 560). However, there was no evidence of a difference in PTSD symptoms when follow-up was less than six months (SMD -0.43, 95% CI -1.41 to 0.56; studies = 3, participants = 146). There may be little or no difference in dropout rates between the I-C/BT and wait list groups (RR 1.39, 95% CI 1.03 to 1.88; studies = 8, participants = 585; low-quality evidence). I-C/BT was no more effective than wait list at reducing the risk of a diagnosis of PTSD after treatment (RR 0.53, 95% CI 0.28 to 1.00; studies = 1, participants = 62; very low-quality evidence). I-C/BT may be associated with a clinically important reduction in symptoms of depression both post-treatment (SMD -0.61, 95% CI -1.17 to -0.05; studies = 5, participants = 425; very low-quality evidence). Very low-quality evidence also suggested that I-C/BT may be associated with a clinically important reduction in symptoms of anxiety post-treatment (SMD -0.67, 95% CI -0.98 to -0.36; studies = 4, participants = 305), and at follow-up less than six months (MD -12.59, 95% CI -20.74 to -4.44; studies = 1, participants = 42; very low-quality evidence). The effects of I-C/BT on quality of life were uncertain (SMD 0.60, 95% CI 0.08 to 1.12; studies = 2, participants = 221; very low-quality evidence).Two studies found no difference in PTSD symptoms between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD -0.08, 95% CI -0.52 to 0.35; studies = 2, participants = 82; very low-quality evidence), or when follow-up was less than six months (SMD 0.08, 95% CI -0.41 to 0.57; studies = 2, participants = 65; very low-quality evidence). However, those who received I-C/BT reported their PTSD symptoms were better at six- to 12-month follow-up (MD -8.83, 95% CI -17.32 to -0.34; studies = 1, participants = 18; very low-quality evidence). Two studies found no difference in depressive symptoms between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD -0.12, 95% CI -0.78 to 0.54; studies = 2, participants = 84; very low-quality evidence) or when follow-up was less than six months (SMD 0.20, 95% CI -0.31 to 0.71; studies = 2, participants = 61; very low-quality evidence). However, those who received I-C/BT reported their depressive symptoms were better at six- to 12-month follow-up (MD -8.34, 95% CI -15.83 to -0.85; studies = 1, participants = 18; very low-quality evidence). Two studies found no difference in symptoms of anxiety between the I-C/BT and I-non-C/BT groups when measured post-treatment (SMD 0.08, 95% CI -0.78 to 0.95; studies = 2, participants = 74; very low-quality evidence) or when follow-up was less than six months (SMD -0.16, 95% CI -0.67 to 0.35; studies = 2, participants = 60; very low-quality evidence). However, those who received I-C/BT reported their symptoms of anxiety were better at six- to 12-month follow-up (MD -8.05, 95% CI -15.20 to -0.90; studies = 1, participants = 18; very low-quality evidence).None of the included studies reported on cost-effectiveness or adverse events.

AUTHORS' CONCLUSIONS

While the review found some beneficial effects of I-C/BT for PTSD, the quality of the evidence was very low due to the small number of included trials. Further work is required to: establish non-inferiority to current first-line interventions, explore mechanisms of change, establish optimal levels of guidance, explore cost-effectiveness, measure adverse events, and determine predictors of efficacy and dropout.

Timely access to mental health care among women veterans

Using survey data on (N = 419) patients at Department of Veterans Affairs (VA) clinics we analyzed women veterans' reports of timely access to VA mental health care. We evaluated problems that patients might face in obtaining care, and examined subjective ratings of VA care as a function of timely access to mental health care. We found that 59% of participants reported "always" getting an appointment for mental health care as soon as needed. In adjusted analyses, two problems were negatively associated with timely access to mental health care: (a) medical appointments that interfere with other activities, and (b) difficulty getting questions answered between visits. Average subjective ratings of VA ranged from 8.2-8.6 out of 10, and 93% of participants would recommend VA care. Subjective ratings of VA were higher among women who reported timely access to mental health care. Findings suggest that overall experience of care is associated with timely access to mental health care, and that such access may be amenable to improvements related to clinic hours or mechanisms for answering patient questions between visits. (PsycINFO Database Record (c) 2019 APA, all rights reserved).