Racial Disparities In Trauma Exposure, Psychiatric Symptoms, and Service Use Among Female Patients In Veterans Affairs Primary Care Clinics

Racial and Ethnic Health Care Disparities Among Women in the Veterans Affairs Healthcare System: A Systematic Review

BACKGROUND

Women are a rapidly growing segment of patients who seek care in the Veterans Affairs (VA) Healthcare System, yet many questions regarding their health care experiences and outcomes remain unanswered. Racial and ethnic disparities have been well-documented in the general population and among veterans; however, prior disparities research conducted in the VA focused primarily on male veterans. We sought to characterize the findings and gaps in the literature on racial and ethnic disparities among women using the VA.

METHODS

We systematically reviewed the literature on racial and ethnic health care disparities exclusively among women using the VA Healthcare System. We included studies that examined health care use, satisfaction, and/or quality, and stratified data by race or ethnicity.

RESULTS

Nine studies of the 2,591 searched met our inclusion criteria. The included studies examined contraception provision/access (n = 3), treatment of low bone mass (n = 1), hormone therapy (n = 1), use of mental health or substance abuse-related services (n = 2), trauma exposure and use of various services (n = 1), and satisfaction with primary care (n = 1). Five of nine studies showed evidence of a significant racial or ethnic difference.

CONCLUSION

In contrast with the wealth of literature examining disparities both among the male veterans and women in non-VA settings, only nine studies examine racial and ethnic disparities specifically among women in the VA Healthcare System. These results demonstrate that there is an unmet need to further assess health care disparities among female VA users.

Vitamin D status and monitoring in female veterans

An increasing number of women are serving in the military. We initiated a retrospective study to evaluate vitamin D status and monitoring in female veterans, and to examine the potential link between vitamin D status, age, race, post-traumatic stress disorder (PTSD), health care costs, and utilization. Approximately 44 percent of the 3,608 female veterans evaluated between 2001 and 2010 were vitamin D deficient (25(OH)D < 20 ng/ml), a rate substantially higher than that of the general population. While younger (<55 years) and older (55+ years) women did not differ significantly in initial vitamin D status, older women had significantly more vitamin D monitoring and follow-up testing than younger women. Approximately 44 percent of vitamin D deficient women did not receive follow-up vitamin D testing. Minority female veterans were most likely to be vitamin D deficient. Female veterans with PTSD did not differ from others regarding their initial vitamin D status; those that were initially deficient were significantly more likely to receive follow-up testing and were more likely to achieve a replete state. Vitamin D deficiency in female veterans was also associated with increased health-care costs. Appropriate monitoring and replacement of vitamin D should be offered to all female veterans.

Ethnic Differences in Personality Disorder Patterns among Women Veterans Diagnosed with PTSD

Personality Disorders (PDs) impair the ability to function socially and occupationally. PD prevalence rates among veterans who have also been diagnosed with posttraumatic stress disorder (PTSD) range from 45%–79%. This study examined ethnic differences in PDs assessed with the Millon Clinical Multiaxial Inventory-III in 260 non-Hispanic white (64%), Hispanic (27%), and African American (9%), mostly single, women veterans in treatment for PTSD. After adjusting for covariates including number and sexual-nature of trauma, findings revealed the adjusted odds ratio of having a cluster A PD was almost three times higher for African Americans (p = 0.046) then the other two ethnic groups, which may be driven by the paranoid PD scale and potentially reflects an adaptive response to racial discrimination. In cluster designation analysis, the odds were twice as high of having a cluster B PD with childhood trauma (p = 0.046), and a cluster C PD with sexual trauma (p = 0.004), demonstrating the significance of childhood and sexual trauma on long-term chronic personality patterns in women veterans. These results highlight the importance of using instruments with demonstrated diagnostic validity for minority populations.

Challenges and Needs Faced by Female Combat Veterans

This article presents findings of a study conducted to identify stressors that may contribute to mental health issues of military female veterans. Female members in the U.S. Armed Forces currently occupy more non-traditional roles; therefore deployment to combat zones, commonly reserved for males, is being taken on by females. While at the present time females serving in the military are not allowed to serve in combat occupations, the reality is that many are being placed in combat roles or environments. Consequently, many are now confronted with stressors related to combat and multiple deployments. This study was based on a descriptive, non-probability, snowball design. In cases where participants displayed a reluctance to share some information in front of counterparts who may have been at a higher or lower rank level; subsequent semi-structured, one-to-one interviews were conducted. The latter approach proved more effective in gathering important information, such as issues of military sexual trauma (MST) and issues of intimacy upon re-entering the home environment. This study was conducted before January 2013, when Defense Secretary Leon Panetta announced the lift of the ban on women serving in combat. Therefore, future studies will need to be conducted to discern how these stressors will affect them in their new role as active combatants.

Physical health status of female veterans: contributions of sex partnership and in-military rape

OBJECTIVE

The aim of this study was to determine whether current physical health status in female veterans is associated with rape during military service and same-sex partnership.

METHODS

Retrospective computer-assisted telephone interviews of 1004 Midwestern US female veterans identified from Veterans Affairs electronic records were conducted. Data included rape history including rape in military, sex partnership history, demographics, and medical history including chronic pain, mental health (depression and posttraumatic stress disorder [PTSD]), and the physical health component of the Short-Form 12-item interview (PCS-12).

RESULTS

Physical health in this sample was lower than norm values [PCS-12: mean (standard deviation) = 43 [12]; norm: mean (standard deviation) = 50 [10]). Fifty-one percent of the participants reported rape in their lifetime, 25% reported rape in military, 11% reported history of women as sex partners, and 71% reported history of chronic pain. Multiple regression analysis indicated that physical health (PCS-12) was associated with chronic pain history (β = -.40, p < .001), rape in military (β = -.09, p = .002), and current PTSD (β = .07, p = .03), adjusting for demographic data. Mediational analysis indicated that chronic pain history significantly mediated relationships of women who have sex with women, childhood rape, PTSD, depression, and current substance use disorder with PCS-12.

CONCLUSIONS

Both rape and sex partnership are adversely associated with lower physical functioning in female veterans. Clinicians evaluating the physical health of this population should therefore consider obtaining detailed sexual histories, and a multidisciplinary team is needed to address mental health issues in female veterans.

Post-traumatic stress disorder symptoms in emotionally distressed individuals referred for a depression prevention intervention: relationship to problem-solving skills

OBJECTIVES

This study examined the rates of syndromal and subthreshold post-traumatic stress disorder (PTSD) and PTSD symptom scores in participants with symptoms of emotional distress, subsyndromal depression, and a history of traumatic exposure. Participants had been referred to a study of an indicated depression prevention intervention using problem-solving therapy in primary care. We hypothesized that higher severity of PTSD symptom scores would predict poorer problem-solving skills. In addition, some reports have suggested that there are higher rates of PTSD in minority populations relative to Caucasians; thus we hypothesized that race would also predict problem-solving skills in these individuals.

METHODS

We examined the rates of traumatic exposure, syndromal, and subthreshold PTSD. In those exposed to trauma, we performed a multiple linear regression to examine the effects of PTSD symptoms, depression symptoms, race, age, and gender on social problem-solving skills.

RESULTS

Of the 244 participants, 64 (26.2%) reported a traumatic event; 6/234 (2.6%) had syndromal PTSD, and 14/234 (6.0%) had subthreshold PTSD. By way of regression analysis, higher PTSD symptom scores predicted poorer problem-solving skills. In addition, racial status (Caucasian vs. African American) predicted problem-solving skills; Caucasians exhibited lower levels of problem-solving skills.

CONCLUSIONS

Individuals presenting with subsyndromal depressive symptoms may also have a history of traumatic exposure, subthreshold and syndromal PTSD. Thus, screening these individuals for PTSD symptoms is important and may inform clinical management decisions because problem-solving skills are lower in those with more severe PTSD symptoms (even after adjusting for race, age, gender, and depressive symptoms).

Racial/ethnic differences in depressive symptoms among young women: the role of intimate partner violence, trauma, and posttraumatic stress disorder

PURPOSE

It is unclear why rates of depression differ by race/ethnicity among young women. This study examines whether racial/ethnic differences in depressive symptoms are reduced by intimate partner violence (IPV), traumatic events, and posttraumatic stress disorder (PTSD) symptoms among a clinical sample of low-income women.

METHODS

A cross-sectional sample of 2414 young African American, Hispanic, and white women completed a survey that included questions about depression, PTSD symptoms, IPV, and trauma. Binary logistic regression and Poisson regression determined whether reports of PTSD symptoms, IPV, and trauma among white, African American, and Hispanic women affected the differences in depression found in these groups.

RESULTS

Twenty-four percent reported a level of depressive symptoms that warranted further evaluation for major depressive disorders. White women had elevated levels of depressive symptoms and were more likely to report ≥4 symptoms. White women also reported higher rates of PTSD symptoms, IPV, and traumatic events than African American or Hispanic women. Differences in the likelihood of reporting ≥4 depressive symptoms by race/ethnicity were reduced after controlling for PTSD symptoms and trauma. PTSD symptoms attenuated the differences in the count of depressive symptoms between white and African American women. After controlling for PTSD symptoms, trauma attenuated the difference in the count of depressive symptoms between Hispanic and white women.

CONCLUSIONS

Elevated levels of trauma and PTSD symptoms among white women compared to African American or Hispanic women may play a role in observed racial/ethnic differences in depressive symptoms.

Ethnic variation in the prevalence of depression and anxiety in primary care: a systematic review and meta-analysis

Primary care plays a key role in the detection and management of depression and anxiety. At present it is not clear if the prevalence of depression and anxiety in primary care differs between migrants and ethnic minorities (MI) and natives and ethnic majorities (MA). A systematic review and a meta-analysis of studies comparing the prevalence of depression and anxiety in MI and MA in primary care were performed. Studies were identified by searching MEDLINE, PsychINFO, EMBASE and through hand-search. We included 25 studies, most of which had a relatively small sample size. Significant variations were found in the prevalence of anxiety and depression across studies. Pooled analyses were carried out for 23 studies, based on random-effects models. Pooled RR of depression and anxiety in MI were 1.21 (95% CI 1.04-1.40, p=0.012) and 1.01 (95% CI 0.76-1.32, p=0.971), with high heterogeneity (I²=87.2% and I²=73%). Differences in prevalence rates among studies can be accounted for by inclusion criteria, sampling methods, diagnostic instruments and study design. Further research on larger samples and with culturally adapted instruments is needed to estimate the prevalence of depression and anxiety in MI seeking help for these disorders.