Presentation looking at pregnancy and mental health care in the VA system. Documents a study examining the prevalence of pregnancy care and comparing the mental health diagnoses among pregnant and non-pregnant women in VA care. Then examining the degree to which pregnant veterans receive VA mental health care during their pregnancy. Concludes that pregnant women veterans using VA care have a substantial mental health burden

Brandt, Cynthia

Goulet, Joseph

Haskell, Sally

Justice, Amy

Krebs, Erin

Mattocks, Kristin M.

Skanderson, Melissa

Yano, Elizabeth M.

English

eScholarship@UMMS

University of Massachusetts Medical School eScholarship@UMMS Women’s Health Research Faculty Publications Women's Faculty Committee 2009-6 Pregnancy and Mental Health Care Among Women Veterans Returning from Iraq and Afghanistan Kristin M. Mattocks University of Massachusetts Medical School Worcester Et al. Let us know how access to this document benefits you. Follow this and additional works at: https://escholarship.umassmed.edu/wfc_pp Repository Citation Mattocks KM, Skanderson M, Goulet J, Haskell S, Yano EM, Krebs E, Justice A, Brandt C. (2009). Pregnancy and Mental Health Care Among Women Veterans Returning from Iraq and Afghanistan. Women’s Health Research Faculty Publications. Retrieved from https://escholarship.umassmed.edu/wfc_pp/588 This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in Women’s Health Research Faculty Publications by an authorized administrator of eScholarship@UMMS. For more information, please contact Lisa.Palmer@umassmed.edu. Pregnancy and Mental Health Care Among Women Veterans Returning from Iraq and AfghanistanK i ti M M tt k 1 2 M li Sk d 1 2 J hr s n . a oc s , , e ssa an erson , , osep  Goulet 1,2, Sally Haskell1,2, Elizabeth Yano3,4, Erin Krebs5, Amy Justice1,2, Cynthia Brandt21Department of Medicine, Yale University School of Medicine, New Haven, CT2VA Connecticut Healthcare System West Haven CT   ,  , 3VA HSR&D Center of Excellence, Center for the Study of Healthcare Provider Behavior, Sepulveda, CA4UCLA School of Public Health Department of Health Services Los Angeles    ,    ,  , CA5 Indiana University, Bloomington, INPregnancy and mental health   • Untreated mental health conditions during     pregnancy may lead to poor maternal outcomes, including substance abuse, loss of employment, divorce, and suicidal ideation/suicide.• May also lead to poor outcomes in offspring, including low birth weight and infant neglect/abuse.M l d i di d i l b• aterna  epress on stu e  extens ve y, ut less is known about PTSD during pregnancy.Women’s military exposure to combat/stress• Women who have served in     Iraq/Afghanistan may have been exposed to extensive combat-related trauma and     stress, including:Direct/indirect combat exposure–   – Difficult living/working conditionsMilitary sexual trauma–   – Exposure to potentially harmful chemical/biological/environmental agents – Multiple deploymentsPregnancy in the VA   • Examining pregnancy and concomitant mental     health problems in the VA is complicated.• Most prenatal care in the VA is provided by fee basis or contract providers outside the VA.• Little information is available regarding the quality of prenatal care, the outcomes of pregnancy, or the degree to which obstetrical i di d i h VA icare s coor nate  w t   pr mary care or mental health providers.Study Objectives  1 Examine prevalence of pregnancy among.      OEF-OIF veterans in Veterans Administration (VA) care  .2. Compare mental health diagnoses among pregnant and non pregnant women in,  - ,   VA care.3 E i th d t hi h t. xam ne e egree o w c  pregnan  veterans receive VA mental health care d i th iur ng e r pregnancy.Methods• Women Veterans Cohort Study    – Phase I:  Administrative cohort of OEF/OIF veterans enrolled in VA (n=452 405)     ,• OEF/OIF roster provided by DOD Defense Manpower Data Center– Those with military discharges from 10/1/2001-04/30/2008.– Veterans must have enrolled for VA services to        be included on roster.– Roster includes:  Race, age, gender, branch, t SSN DOB it l t t d ticomponen , , , mar a  s a us, e uca on.Methods (continued) • Roster linked to:  – VA National Patient Care Database (NCPD): All diagnostic and encounter data including      ICD-9-CM codes, CPT codes, V codes, and stop codes (VA system for tracking utilization).– VA Decision Support Systems (DSS):  All VA/fee basis cost data; laboratory data; pharmacy data.Defining/measuring pregnancy • To ensure independence of observation     (one pregnancy/veteran), an ‘index pregnancy’ was identified as unit of      analysis.• Index pregnancy was determined if a      female veteran had any one pregnancy-related ICD9 CPT or V code within the , ,      seven year observation period of the available NCPD/DSS data  . Defining/measuring mental health diagnoses• Veterans were considered to have mental      health diagnoses if they had 2 outpatient or 1 inpatient ICD-9-CM codes for     depression, bipolar disorder, PTSD, or schizophrenia.Measuring mental health care utilization during pregnancy• Because the VA does not provide routine       prenatal care or collect pregnancy outcomes it can be difficult to measure,       tenure of pregnancy.• Consequently difficult to measure mental,     health care utilization during pregnancy.T d t d ‘ i d ’• o o so, we crea e  pregnancy w n ow :  +/- 10 months of first pregnancy-related d i VAco e n .Comparisons to non-pregnant women veterans• To evaluate how pregnant women     veterans may be different from their non-pregnant veteran counterparts we created  ,   a comparator group of all non-pregnant women veterans between the ages of 18-      50 who were enrolled in VA care.• Enabled us to examine mental health      diagnoses, but not utilization (in progress).Analysis• Univariate and bivariate statistics (e.g. the t test for continuous and χ2 test for ordinal or dichotomous variables) were used to compare the demographic and clinical characteristics of women veterans with and       without pregnancy.  • Logistic regression models were used examine the relationship between mental health diagnoses, adjusting for covariates including age education marital status   , ,  , branch, rank, race, and substance abuse.  Results• 43 078 women veterans between the ages,       of 18-50 utilized VA care at least once during the 2001-2008 study period    .• Of these women, 2966 (7%) were identified as having an index pregnancy      during the study period (had at least 1 ICD 9 CPT or V code)- , ,   .– Validation:  73% of the 2966 women had a second pregnancy related code within 10 -     months of first code.Characteristics of pregnant veterans in VA care• Pregnant veterans were younger (24 vs     . 29), and more likely to be Hispanic, unmarried and have a high school,      education or less  than non-pregnant women veterans (p< 0001)  . .• Pregnant veterans were also more likely to be enlisted service members rather than       officers, and more likely to be active duty service members rather than members of      the Guard or Reserves (p<.0001).Table 1: Distribution of pregnancy among women t bve erans, y yearYear of index At least one 2 or more % with 2 or pregnancy pregnancy code (n)codes within10 months (n)more codes in 10 months2002 12 6 50%2003 61 25 41%2004 356 212 60%2005 588 417 71%2006 955 714 75%2007 905 696 77%2008* 89 89 100%Table 2:  Distribution of pregnancy-related d t t ( 2966)co es among pregnan  ve erans n=  Type of pregnancy code (ICD-9-CM) % pregnant women with codeFee Basis Care (non-VA providers)Normal pregnancy/delivery 44%Ectopic/molar pregnancy 5 8% .Miscarriage/spontaneous abortion 5%V Code 75%VA CareNormal pregnancy/delivery 0.8%Ectopic/molar pregnancy 1.6%Miscarriage/spontaneous abortion 3.4%V Code 61%Table 3:  Mental health diagnoses among t d t t i VApregnan , an  non-pregnan , ve erans n  careDiagnosis All female Pregnant p % pregnant women  veterans (n=40,112)veterans (n=2966)with condition prior to pregnancyMajor d i5% 12% <.0001 61%epress onMild depression 10% 24% <.0001 62%PTSD 9% 21% <.0001 66%Bipolar disorder 1% 3% <.0001 55%Schizophrenia 0.11% 0.33% <.0001 44%Any MH diagnoses20% 32% <.0001 22%Substance abuse disorder2% 5% <.0001 56%Table 4:  Final model of logistic regression of t l h lth dipregnancy on men a  ea  agnosesVariable Odds Ratio (95% CI)Pregnancy 1.91 (1.75, 2.08) Army 1.54 (1.43, 1.67)Air Force 0 86 ( 78 95) .  . , .Marines 1.23 (1.06, 1.43)Age 0.83 (.78, .87)Enlisted 1.56 (1.07, 2.24)Married 0.94 (.89, .99)Substance abuse 25.51 (21.43, 30.36)Table 5:  VA mental health care utilization during i dpregnancy w n owType of visit % pregnant women visiting during pregnancy window (average # of visits during window)Mental health clinic—individual 33% (avg. 6.6 visits)PTSD, individual or group 9% (avg. 6.9 visits)Substance abuse treatment—individual2% (avg. 9.1 visits)Sexual trauma counseling 1% (avg. 8.1 visits)Conclusions• Pregnant women veterans utilizing VA care have a substantial mental health burden.• Dual systems of care:  VA care for mental health and it b d b t t i lcommun y- ase  o s e r ca  care.• Further research should examine the quality of community-based obstetrical care, and the degree to       which care is coordinated between VA and non-VA providers.O t it f VA t d l h d t f• ppor un y or  o eve op en ance  sys em o  coordinated, high quality care for its women veterans.

Pregnancy and Mental Health Care Among Women Veterans Returning from Iraq and Afghanistan

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Pregnancy and Mental Health Care Among Women Veterans Returning from Iraq and Afghanistan

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