Mental Health Across the Reproductive Cycle in Women Veterans

Suicidal Ideation and Suicide Attempts Among Women Veterans Using VA Reproductive Health Care: Prevalence and Associations With Fertility-, Pregnancy- and Parenting-related Factors

INTRODUCTION

Women veterans are at elevated risk for suicide and experience a high prevalence of suicidal ideation (SI) and suicide attempt (SA) history. Knowledge regarding SI/SA correlates among women veterans who use reproductive health care services is limited, inhibiting development of evidence-based, gender-sensitive suicide prevention programming tailored to meet women veterans' needs and preferences. This study aimed to 1) describe the prevalence and characteristics of SI and SA among women veterans using Veterans Health Administration (VHA) reproductive health care services and 2) provide an initial exploration of associations between fertility-, pregnancy-, and parenting-related factors with SI and SA to guide future research.

METHODS

Post-9/11 women veterans (n = 352) who used VHA reproductive health care in fiscal year 2018 completed a cross-sectional survey on reproductive health, mental health, and parenting.

RESULTS

Approximately 30% and 12% experienced SI and SA(s), respectively, after military service; 10% reported past-month SI. Infertility, pregnancy loss, age at first pregnancy, and parental status were not significantly associated with SI or SA history, although notable effect sizes were observed for infertility and age at first pregnancy; further research is warranted. Among parents, parental functioning was not associated with SI/SA, but lower parental satisfaction was significantly associated with past-month SI (prevalence ratio, 3.36; 95% confidence interval, 1.19-9.46; adjusting for demographics, military characteristics, mental health symptoms).

CONCLUSIONS

Postmilitary SI and SA(s) are common among women veterans accessing VHA reproductive health care services. Those with low parental satisfaction may be at particularly high risk. Findings can guide future research and inform clinical care to facilitate suicide prevention.

The Impact of Military Trauma Exposures on Servicewomen's Pregnancy Outcomes: A Scoping Review

INTRODUCTION

Active-duty servicewomen and veterans make up nearly 20% of the United States military and may experience trauma specific to military service. Military-specific trauma includes combat deployment and military sexual trauma, exposure to which may result in posttraumatic stress disorder (PTSD). The purpose of this scoping review is to examine the extent to which military trauma exposures impact the pregnancy outcomes of active-duty servicewomen and women veterans.

METHODS

A systematic search of OVID MEDLINE, OVID Embase, and OVID PsycINFO from inception to September 25, 2023, identified studies examining associations between military trauma exposures and perinatal outcomes. Of the 614 studies identified, 464 were reviewed for relevance, with 16 meeting inclusion criteria.

RESULTS

Of the 16 included studies, 14 found associations between military trauma exposure and adverse pregnancy outcomes including preterm birth, gestational diabetes, hypertensive disorders of pregnancy, low birth weight, and perinatal mood and anxiety disorders. The risks of adverse pregnancy outcomes increased with the severity of PTSD, the recency of combat deployment, and repetitive deployment.

DISCUSSION

This scoping review strengthens the link between trauma exposures and adverse pregnancy outcomes for current and former military servicewomen. A gap in the literature persists regarding trauma exposure among active-duty servicewomen, which differs significantly from women veterans. As mental health conditions are the leading underlying cause of maternal mortality, standardized screening during the perinatal period for military-specific trauma exposures and PTSD is recommended for this population. Black servicewomen of junior enlisted rank carry disproportionate burdens of PTSD diagnosis and adverse pregnancy outcomes. Comprehensive prenatal and postpartum management may improve perinatal and neonatal outcomes for military servicewomen and provide an innovative approach to reducing existing racial disparities.

Predictors of Early Postpartum Maternal Functioning Among Women Veterans

INTRODUCTION

The perinatal period constitutes an important window of opportunity for optimizing healthy development of offspring but is heavily influenced by maternal mental health. Maternal pregnancy-related anxiety (PrA), depression, and post-traumatic stress disorder (PTSD) have been implicated in adverse outcomes for both mother and child. The current study examined whether psychopathology during pregnancy and postpartum was associated with greater experienced parenting stress and bonding difficulties in women veterans, who may be predisposed to develop psychopathology due to heightened risk of exposure to traumatic events.

METHODS

Pregnant veterans (N = 28) completed self-report questionnaires regarding their PrA, depression and PTSD symptoms during pregnancy and postpartum, as well as on their experience of parenting stress and bonding with their infant.

RESULTS

PrA was a more robust predictor of postpartum depression (PPD) than depression during pregnancy. PPD, in turn, was significantly associated with bonding and parenting stress, such that more depressed mothers were more likely to experience greater general bonding difficulties, increased rejections and pathological anger towards their infants, greater anxiety towards their infants, and more parenting stress.

CONCLUSIONS

PrA might be a high-yield modifiable risk factor in the prevention of PPD for women veterans and their subsequent experiences with high parenting stress and bonding difficulties.

Are alterations in estradiol, cortisol, and inflammatory cytokines associated with depression during pregnancy and postpartum? An exploratory study

Background

Pregnant veterans are a subpopulation known to be at elevated risk of developing mental health symptoms, such as depression and suicidal ideation. Inflammation has been associated with depression, specifically during the perinatal period. Critical changes in estradiol, cortisol, and inflammatory cytokines are necessary for the progression of a healthy pregnancy, which are then rapidly altered in the postpartum period. We explored changes in estradiol, cortisol, and pro-inflammatory cytokines relative to depressive symptoms and suicidal thoughts across pregnancy and postpartum in this pilot and feasibility study.

Methods

We measured estradiol, cortisol, and the inflammatory cytokines IL-1β, IL-6, IL-8, IFN-γ, and TNF-α in 18 pregnant veterans and analyzed the data using descriptive statistics, dependent t-tests, and correlation analyses. We assessed depression severity with the Edinburgh Postnatal Depression Scale and suicidality with the Columbia-Suicide Severity Rating Scale. Thirteen of the women repeated assessments in the early postpartum period at an average of 6.7 weeks after birth.

Results

As anticipated, estradiol (t(12) ​= ​12.47, p ​< ​.001) and cortisol (t(12) ​= ​9.43, p ​< ​.001) significantly decreased from pregnancy to postpartum. There were no differences in the means of gestational and postpartum IL-1β, IL-6, TNF-α, or IFN-γ, but IL-8 was significantly increased from pregnancy to postpartum (t(12) ​= ​-4.60, p ​= ​.001). Estradiol during pregnancy was positively correlated with IL-6 levels both during pregnancy (r _p  ​= ​.656, p ​= ​.008) and postpartum (r ​= ​0.648, p ​= ​.023). Elevated IL-1β was associated with suicidal thoughts during pregnancy (r ​= ​0.529, p ​= ​.029). Although not statistically significant, depressive symptom severity trended towards a positive association with larger increases in IL-1β (r ​= ​0.535, p ​= ​.09) and TNF-α (r ​= ​0.501, p ​= ​.08) from pregnancy to postpartum.

Conclusion

This preliminary study suggests the feasibility of our approach for exploring a complex interplay between hormonal and pro-inflammatory changes from pregnancy to postpartum, and their relationship with depressive symptoms. Given our small sample and the relatively exploratory nature of our analyses, additional investigation focusing on hormonal and inflammatory changes and their potential associations with perinatal mental health is necessary to confirm and extend our preliminary findings and examine additional potential covariates.

Women's Mental Health in the U.S. Military - Where Are We Now? A Review of Recent Research

PURPOSE OF REVIEW

The field of women's mental health has grown in the military healthcare system, which has begun to acknowledge and address the sex-specific differences in mental health for service women. The purpose of this review is to examine recent research in active duty populations addressing perinatal mental health, post-traumatic stress disorder (PTSD), depression, and gender isolation.

RECENT FINDINGS

Within the examined literature focused on active duty populations, analyses by sex and gender continue to exist as notable gaps, and a majority of studies reviewed either do not aim to examine sex or gender-based differences, and/or do not analyze data with an eye towards these paradigms. Within perinatal mental health, the lack of studies led to an inability to make any notable conclusions. PTSD was the area with the most robust publications focused on active duty women, studies of major depression showed significant occupational impact, and the area of gender isolation continues to grow as a promising field with practical implications. We discuss current promising research and advance ideas for future research trajectories that will provide clinicians, policy makers, and scientists with more data to support improved mental healthcare for both military women and men.

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.

Examining Rates of Postpartum Depression in Active Duty U.S. Military Servicewomen

Background: Postpartum depression (PPD) is understudied in military populations. The present descriptive transversal study evaluated the incidence of PPD diagnoses in U.S. military electronic health records, based on International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes, among active duty military servicewomen between 2001 and 2018. Methods: Data on 3,724 active duty military servicewomen who served between 2001 and 2018 were drawn from the Defense Medical Epidemiological Database and stratified by race, age, marital status, service branch, and military pay grade. Single sample chi squares were used to examine observed versus expected differences in diagnosis rates. Results: The incidence rate of PPD among all U.S. military servicewomen was the lowest in 2001 (1.96 per 1,000) and the highest in 2018 (29.95 per 1,000). Servicewomen most often diagnosed with PPD were white (60%), married (74%), in the enlisted pay grades of E-1 to E-4 (60%), in the Army (43%), and were between 20 and 24 years old (46%). Statistically significant differences (p < 0.001) were found between observed and expected counts across all five demographic variables. Conclusions: This is the first population-based study to assess the incidence rates of PPD among all active duty military servicewomen. Findings that some groups were over- and underdiagnosed within each demographic category, and that PPD incidence rates have increased between 2001 and 2018, underscore the importance of further research to inform policies and interventions supporting this vulnerable population.

Innovations for integrated care: The Association of Medicine and Psychiatry recognizes new models

This editorial looks at the current state of the integration of medicine and psychiatry in clinical practice. We note selected recent triumphs and barriers to implementing integrated care, highlighting some gaps and priorities for future innovations. In contrast to the relatively more orderly culture of health services research, where some notable innovations in integrated care were funded, tested, and published, the health care marketplace can be a difficult place to identify and track the innovations that could shape health care reform. Recognizing the need to find, describe, and disseminate the most innovative models in integrated care, the Association of Medicine and Psychiatry (AMP) launched in 2016 the Innovative Models for Integrated Care Awards. Although many service innovations solve local problems, some can also act as models to be adopted in multiple settings. The projects that win AMP Innovative Models for Integrated Care Awards are selected for their innovativeness, their clinical importance, their generalizability, and their effectiveness. We briefly describe here the four models that earned these awards at the 2017 AMP Annual Meeting. They demonstrate innovations across a range of settings and populations: inpatient general hospital patients under constant observation in New York, severely mentally ill patients in a federally qualified health center in San Francisco, outpatients in a VA women's health center in Chicago, and HIV patients in an academic infectious disease clinic in Charleston, south Carolina. These model descriptions aim to encourage the implementation of innovative models that advance the integration of medicine and psychiatry.