Association Between Mental Health Burden and Coronary Artery Disease in U.S. Women Veterans Over 45: A National Cross-Sectional Study

Barriers to Screening, Diagnosis, and Prevention of Cardiovascular Disease in Women Veterans

INTRODUCTION

Veterans are known to be at high risk for cardiovascular disease. Women veterans are not only a part of this specialty group, but as they are women-they face some unique experiences and barriers to cardiovascular care that their male counterparts do not. The purpose of this article is to identify barriers as well as facilitators to screening, prevention, and diagnosis of cardiovascular care to women veterans.

MATERIALS AND METHODS

A literature review was conducted, utilizing the keywords "veterans" AND "female" AND "cardiovascular disease or heart disease" AND "screening or prevention or diagnosis" in CINAHL and PubMed; as well as a search in SCOPUS using "barriers" AND "veteran" AND "female" AND "Cardiovascular."

RESULTS

Patient-level barriers included social determinant of health determinant issues, lack of social support, being unaware of their risk of cardiovascular disease or how to implement heart-healthy diet and exercise, and gender bias via the Veterans Affairs staff or provider. Provider level barriers included not having enough time with the patient, not having information on resources for women veterans that are available, the electronic medical record not having screening tools for the provider and patient to use together for discussion or not having the ability to communicate the risk education and recommendations.

CONCLUSIONS

The gaps in care brought to light in this article make the case for patient and provider tools that include considerations such as mental health, gender-specific care, and education surrounding their risk status and how to access resources to implement healthy lifestyle changes.

Challenges to Cardiovascular Health Among Female U.S. Veterans and Future Implications: A Scoping Review

INTRODUCTION

Cardiovascular disease (CVD) is the leading cause of death for women in the United States, and U.S. female Veterans have higher rates of CVD compared to civilian women. With an increasing number of women joining the military, the number of female Veterans is expected to rise; therefore, providing appropriate cardiovascular care must be a top priority for the DoD and the Veterans Health Administration (VHA). This scoping review will answer the question: "Among U.S. female Veterans, what are the challenges faced in cardiovascular health, and what are potential future implications and interventions?" We designed this scoping review to identify common themes and gaps in the literature, guide further investigations, and contribute to developing targeted interventions and policies to enhance cardiovascular outcomes among female Veterans.

MATERIALS AND METHODS

On May 1, 2024, a modified PRISMA-ScR search was performed using the following online databases: PubMed, CINAHL, and OVID. The inclusion criteria included U.S. female Veterans, CVD, and data collected from VHA database sources. Results from any literature source published in the past 10 years and written in English were considered. The search identified 107 studies. Two independent reviewers screened titles and abstracts and then performed full-text reviews.

RESULTS

We identified 34 studies assessing challenges to cardiovascular care among female Veterans in areas of racial/ethnic and gender-specific disparities regarding the prevalence of nontraditional CVD risk factors, access to health care services, awareness and knowledge of CVD risk factors, and willingness to receive cardiovascular care. The review also identified potential areas for improvement initiatives in education, peer support, and future research.

CONCLUSIONS

This review highlighted 3 main challenges female Veterans face in accessing CVD care from the VHA: perceived barriers, unique risk factors, and gender/racial disparities. It emphasized the need for improved CVD research, screening, education, and social support for female Veterans. The authors propose two main strategies to address these challenges: (1) pre-transition education from the DoD and (2) enhanced CVD training in the VHA. Cardiovascular disease risk factor recognition and prevention education should occur in military settings, allowing medical providers in DoD clinics to engage female service members in discussions and screenings before transitioning to VHA care. The VHA should educate providers on the barriers female Veterans face, the identification of nontraditional risk factors, and existing health care disparities. Additionally, it should continue to support successful initiatives focused on improving CVD care for female Veterans, such as the Women's Health Research Network, the Quality Enhancement Research Initiative, and the Enhancing Mental and Physical Health of Women through Engagement and Retention program.

An Evidence Map of the Women Veterans' Health Literature, 2016 to 2023: A Systematic Review

Importance

Women veterans are the fastest-growing veteran subpopulation in the US. Women veterans often experience military service-related health issues in addition to conditions common to all women. Because women veterans are more likely to receive care in the civilian setting than through the Department of Veterans Affairs (VA), all women's health clinicians should be equipped to provide patient-centered care for women veterans. The health care of women veterans requires evidence-based care informed by population-specific scientific literature. An updated evidence map evaluating women veteran-focused health literature is needed.

Objective

To map the scope and breadth of women veterans' health literature published from 2016 to 2023.

Evidence Review

In this systematic review, MEDLINE, Embase, and CINAHL Complete were searched for eligible articles published from 2016 to 2023. Articles reporting about US women veterans' health outcomes or on the experience of providing care to women veterans were included. Included articles were required to report patient-level outcomes that included either data for only women veterans or reported results separately for women veterans. Articles were grouped by primary focus area based on categories previously established by the VA Women's Health research agendas and prior evidence maps.

Findings

The volume of women veterans' health literature published between 2016 and 2023 of 932 articles was double that of the prior 8 years. The largest portion of this literature was focused on chronic medical conditions (137 articles [15%]), general mental health (203 articles [22%]), and interpersonal violence (121 articles 3[13%]). Areas of greatest growth included reproductive health (physical and mental), pain, suicide, and nonsuicidal self-injury. Additionally, emerging areas of inquiry were found, including military-related toxic exposures and harassment within the health care setting.

Conclusions and Relevance

In this systematic review of literature focused on the health of women veterans, the volume of literature was found to have doubled and expanded in important areas that aligned with VA research priorities. However, despite the growth in research related to women veterans, several important research gaps remain within this field of study. Research addressing health issues pertinent to a growing and aging women veterans' population will require rigorous research and program evaluations.

The Association Between Chronic Disease and Psychological Distress: An Australian Twin Study

There is a commonly observed association between chronic disease and psychological distress, but many potential factors could confound this association. This study investigated the association using a powerful twin study design that can control for unmeasured confounders that are shared between twins, including genetic and environmental factors. We used twin-paired cross-sectional data from the Adult Health and Lifestyle Questionnaire collected by Twins Research Australia from 2014 to 2017. Linear regression models fitted using maximum likelihood estimations (MLE) were used to test the association between self-reported chronic disease status and psychological distress, measured by the Kessler Psychological Distress Scale (K6). When comparing between twin pairs, having any chronic disease was associated with a 1.29 increase in K6 (95% CI: 0.91, 1.66; p < .001). When comparing twins within a pair, having any chronic disease was associated with a 0.36 increase in K6 (95% CI: 0.002, 0.71; p = .049). This within-pair estimate is of most interest as comparing twins within a pair naturally controls for shared factors such as genes, age and shared lived experiences. Whereas the between-pair estimate does not. The weaker effect found within pairs tells us that genetic and environmental factors shared between twins confounds the relationship between chronic disease and psychological distress. This suggests that associations found in unrelated samples may show exaggerated estimates.

Mental Health and Psychosocial Functioning in Recently Separated U.S. Women Veterans: Trajectories and Bi-Directional Relationships

Prior research on the relationship between veterans' mental health and psychosocial functioning has primarily relied on male samples. Here, we investigated prospective longitudinal relationships between mental health and psychosocial functioning in 554 female Iraq and Afghanistan War veterans who were surveyed three times between two- and seven-years following separation from service. Mixed effects modeling revealed that increasing depression and posttraumatic stress disorder (PTSD) severity predicted declines in work functioning. Increasing PTSD severity predicted declining parental functioning and worsening depression predicted a decline in relationship functioning. In turn, decreased work and intimate relationship functioning predicted increased PTSD and depression symptom severity suggesting bi-directional effects between mental health and psychosocial functioning. An examination of the effect of deployment stressors on psychosocial functioning revealed that deployment sexual harassment was the strongest predictor of decreased psychosocial functioning across all domains. Evidence for the reciprocal nature of relationships between mental health and psychosocial functioning underscore the need for treatment targeted at PTSD and depression, as well as work and relationship functioning to improve outcomes for women veterans.

CYP2C19 genotype, physician prescribing pattern, and risk for long QT on serotonin selective reuptake inhibitors

Aim: To examine the impact of CYP2C19 genotype on selective serotonin reuptake inhibitor (SSRI) prescribing patterns. Patients & methods: Observational cohort containing 507 unique individuals receiving an SSRI prescription with CYP2C19 genotype already in their electronic medical record. Genotype was distributed as follows: n = 360 (71%) had no loss of function alleles, 136 (26.8%) had one loss of function allele and 11 (2.2%) had two loss of function alleles. Results & conclusion: For poor metabolizers exposed to sertraline, citalopram or escitalopram, providers changed prescribing patterns in response to alerts in the electronic medical record by either changing the drug, changing the dose or monitoring serial EKGs longitudinally. For intermediate metabolizers exposed to sertraline, citalopram or escitalopram, no alert was needed (mean QTc = 440.338 ms [SD = 31.1273] for CYP2C19*1/*1, mean QTc = 440.371 ms [SD = 29.2706] for CYP2C19*1/*2; p = 0.995).

Civic Service as an Intervention to Promote Psychosocial Health and Implications for Mental Health in Post-9/11/01 Era Women Veterans

Background: Women veterans experience significant morbidity with poorer health and mental health outcomes relative to nonveteran counterparts. Little is known about how to best promote health and well-being among reintegrating female veterans. Civic service has been shown to improve mental health in civilians, but its impact on female veterans is unknown. This study characterizes the physical and mental health and psychosocial functioning of female veterans and evaluates changes in these domains following completion of an intensive civic service program. Materials and Methods: Data were obtained from an observational, pre-post cohort study of post-9/11/01 era veterans who completed a 6-month, 20-hour per week civic service program. Of the 346 participants, 107 were women. Participants completed online pre- and post-program surveys. Nine measures of health, mental health, and psychosocial functioning were analyzed. Results: Before starting the program, 47% of women screened positive for a probable diagnosis of post-traumatic stress disorder (PTSD), 24% for depression, and 51% reported seeking assistance for mental health problems. Pre-post change scores indicated significant improvements on nine measures of health, mental health, and psychosocial functioning (p < 0.05). Perceived self-efficacy change scores predicted PTSD change scores, F(1, 93) = 8.00, p < 0.05. Seeking professional assistance for mental health problems and social isolation and loneliness change scores predicted depression change scores, F(2, 95) = 15.618, p < 0.05, explaining 23% of the variance. Conclusions: Civic service has the potential to promote and support the maintenance of psychosocial well-being for returning post-9/11/01 era women veterans with symptoms of PTSD or depression.