Comparison between Women-Only and Mixed-Gender Intensive PTSD Treatment for Female Veterans
August 2, 2019
Women veterans diagnosed with PTSD are an especially rapidly growing subgroup of VHA patients (Washington, Davis, Der-Martirosian, & Yano, 2013), constituting 10.3% of all those diagnosed with PTSD in 2015. With the recognition that women veterans with PTSD have often experienced different types of trauma and have different needs than men, specialized intensive treatment is also offered in two specialized intensive Women’s Treatment Rehabilitation Programs (Karlin et al., 2010). These programs were established on the premise that vulnerable populations are often best served by specialized programs that are staffed by clinicians who have, or who can develop, a special sensitivity to and expertise concerning the unique clinical needs of these populations.
There has long been concern that women may experience additional stress when treated for PTSD in the predominantly male environment of the VHA and some have speculated that VHA clinicians may not have adequate experience and skills for treating women (Fontana & Rosenheck, 2006; Fontana, Rosenheck, & Desai, 2010; Mouilso, Tuerk, Schnurr, & Rauch, 2016).
Using national program evaluation data from specialized intensive VHA PTSD treatment programs in fiscal year 1996 to 2011, we have investigated whether women veterans experience more or less clinical improvement when treated in women-only as compared to mixed- gender programs. Data were collected at program entry and four months after discharge on 1,357 women Veterans from 57 sites. With adjustment for differences in baseline characteristics, outcomes of women in two women-only programs (n=469) were compared with those from 55 mixed-gender programs (n=888) using mixed models with random effect for site.
Participants in the women-only programs, were more likely to have a PTSD service-connected disability, and less likely to self-identify as black, to report war zone service, or to have received incoming fire. They were also more likely to have experienced sexual trauma during military active duty as well as less likely to attempted suicide in the past four months. With regard to clinical characteristics, female veterans in the women-only programs were more likely to be diagnosed with affective disorder and less likely to have been diagnosed with drug dependence or bipolar disorder.
Women treated in the women-only programs were more likely to have been admitted during the earlier years of the program evaluation, had significantly longer lengths of stay, and were reported by their clinicians at discharge to have been personally more committed to treatment. Each of these variables was found to be associated with superior outcomes the total PTSD score and some subscales, making them potential mediators of outcome and, thus, confounders of the evaluation of differences in outcomes between program types. Women in the women-only programs had significantly lower total PTSD symptom score and lower scores on all subscales with small to medium effect sizes as compared to those treated in mixed-gender programs.
Of those admitted, 865 (63.7%) were successfully followed up after discharge, including 326 (69.5%) of those in the women-only programs and 539 (60.7%) in the mixed-gender programs (χ2 =10.3(1), p=.001). Notably neither baseline levels of the primary outcome measure, total PTSD symptoms, nor of any of the secondary outcomes variables, was associated with missing data at follow-up. Non-combat related non-sexual trauma was more strongly associated with missing data in the women only program than in the mixed gender program. However, this baseline variable was not significantly associated with the degree of change in PTSD outcomes or any other outcome measure and consequently could not have biased the comparison of outcomes between program types. On process measures women successfully followed up in women-only programs were judged by their clinicians to have been significantly more committed to treatment at discharge (β= .69, p= .001) but did not differ significantly from those not followed-up on any baseline measure. Overall outcomes from baseline to follow-up showed small to moderate effect sizes on PTSD symptoms and subscales and ranged from - .55 for the PTSD total score to - .23 on irritability symptoms; and less than small effects on ASI measures (- .02 to - .09)
Post-discharge clinical change
Comparison of clinical changes by program types from admission to post-discharge assessment, adjusted for the baseline socio-demographic, military service, and clinical differences between participants in the program types revealed that female veterans treated in the women-only program showed no significantly greater improvement in the primary outcome, the PTSD total score, or on secondary measures, the PTSD subscales or on the ASI measures with effect sizes in the less-than-small range (0<d < 0.16) although the direction of non-significant differences favored the women-only programs.
These analyses were repeated with treatment participation variables that were significantly associated with both: (1) being treated in women-only programs and (2) superior PTSD outcomes included as covariates. The addition of these co-variates, length of stay and commitment to therapy, did not change the results of the previous analysis as female veterans treated in the women-only program still showed no significantly greater improvement in the PTSD total score or subscales or on ASI measures with effect sizes in the less-than-small range (0 < d < 0.14).
Although several significant differences in clinical presentation suggest that women in the women-only programs had less severe symptoms at the time of admission, there were no significant differences in treatment outcomes between the two types of programs on PTSD total symptom scores, subscales, or other measures. Women treated in women-only programs had longer lengths of stay and were reported by their clinicians to have been more committed to treatment. Nevertheless, adjusting for these potential mediators of better outcomes in the women-only programs did not change the results. Contrary to our hypothesis, the results of this study did not provide evidence that female veterans treated in woman-only programs show greater clinical improvement than those treated in mixed-gender, predominantly male, programs, but should encourage future research to identify gender-specific factors that may enhance the effectiveness of treatment for female veterans with PTSD. Additionally, it is noteworthy that participants in the women-only programs had longer lengths of stay, were more committed to treatment, and had outcomes comparable to those in the mixed-gender programs, all of which suggests that they ultimately succeeded in reaching their goals.
Fontana, A., & Rosenheck, R. (2006). Treatment of female veterans with posttraumatic stress disorder: The role of comfort in a predominantly male environment. Psychiatric Quarterly, 77(1), 55-67.
Fontana, A., Rosenheck, R., & Desai, R. (2010). Female veterans of Iraq and Afghanistan seeking care from VA specialized PTSD programs: Comparison with male veterans and female war zone veterans of previous eras. Journal of Women's Health, 19(4), 751-757.
Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. M., Hembree, E. A., . . . Foa, E. B. (2010). Dissemination of evidence‐based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of traumatic stress, 23(6), 663-673.
Mouilso, E. R., Tuerk, P. W., Schnurr, P. P., & Rauch, S. A. (2016). Addressing the gender gap: Prolonged exposure for PTSD in veterans. Psychological services, 13(3), 308.
Washington, D. L., Davis, T. D., Der-Martirosian, C., & Yano, E. M. (2013). PTSD risk and mental health care engagement in a multi-war era community sample of women veterans. Journal of General Internal Medicine, 28(7), 894-900.
Stefanovics, E. A. and Rosenheck, R. A. (2019), Comparing Outcomes of Women‐Only and Mixed‐Gender Intensive Posttraumatic Stress Disorder Treatment for Female Veterans. JOURNAL OF TRAUMATIC STRESS, 32: 606-615. doi:10.1002/jts.22417
Questions for Discussion:
What are the distinct treatment needs of women veterans with PTSD?
How might women-only services improve PTSD treatment for female veterans?
How do we compare the importance of improvements in treatment outcomes and in treatment processes (e.g. satisfaction).
About the Authors
Elina A. Stefanovics, PhD is Research Scientist at the Department of Psychiatry, Yale University School of Medicine, and Biostatistician at the VA New England Mental Illness Research and Education Center (MIRECC)
Robert A Rosenheck, MD is Professor of Psychiatry, Epidemiology and Publics Health, and the Child Study Center, Yale University, School of Medicine and Senior Research Investigator at the VA New England Mental Illness Research and Education Center (MIRECC)