Improving the perinatal mental health of Veterans with serious mental illness through peer support
openNIH
SIGNIFICANCE TO VA: In the past decade, the number of women Veterans of childbearing age using VA has
nearly doubled, and over forty percent of these women have a diagnosis of serious mental illness (SMI; major
depressive disorder, posttraumatic stress disorder, bipolar disorder, schizophrenia, other psychotic disorders).
Veterans experience worse pregnancy and birth outcomes than civilians, a disparity largely attributed to their
high burden of mental illness and trauma. Pregnant and postpartum Veterans with SMI—who often have
numerous mental health, medical, and social challenges—are at high risk for perinatal exacerbation of mental
illness, with consequences including maternal morbidity and mortality, poor functioning, and impaired child
development. Reach Out, Stay Strong Essentials (ROSE), a brief evidence-based psychoeducational
intervention for prevention of postpartum depression in women without mental illness, is being implemented in
over two dozen VA facilities; feedback from ROSE implementers supports its use, but with noted limitations for
Veterans with SMI. Building on lessons learned from ROSE implementation, I propose to develop and pilot
ROSE+, a psychosocial intervention blending ROSE with peer support (i.e., support provided by Veteran peer
specialists with personal experience of mental illness). Peer support is a key component of VA mental health
care; while evidence exists for peer support in non-SMI perinatal and non-perinatal SMI populations, existing
interventions are limited in applicability to the complex social, medical, and mental health needs of perinatal
Veterans with SMI. ROSE+ will comprise adapted and combined components of ROSE and evidence-based
perinatal and SMI peer support models, tailored to the VA context and the unique needs of perinatal Veterans
with SMI. Developed in partnership with VA Office of Women’s Health and Office of Mental Health, this
proposal aligns with key VA operations and HSR priorities including women’s health, mental health, maternal
health, peer support, and Veteran engagement, and will fill a key gap in care for perinatal Veterans with SMI.
INNOVATION & IMPACT: This research will not only set the foundation for the first perinatal mental health
intervention for Veterans with SMI, but will also identify additional opportunities to strengthen VA perinatal
mental health services and care coordination via an IIR submission in Year 3. SPECIFIC AIMS: 1) Engage
Veterans and key VA clinical staff in identifying potential components of ROSE+; 2) Develop and refine the
ROSE+ intervention; 3) Assess the feasibility, acceptability, and exploratory outcomes of ROSE+ in a pilot
study. METHODOLOGY: Intervention development will be guided by the Transcreation Framework, an
implementation science framework for community-partnered development of behavioral interventions for
vulnerable populations. Aim 1: To assess the experiences, needs, and care preferences of perinatal Veterans
with SMI and inform potential intervention components, I will conduct semi-structured interviews with pregnant
and postpartum Veterans with SMI and VA women’s mental health providers, followed by focus groups with VA
Maternity Care Coordinators and women VA peer specialists. Aim 2: Using Delphi methodology, I will present
potential intervention components—drawn from existing interventions and accompanied by data from the
literature and Aim 1 findings—to an expert panel of VA multilevel constituents to identify final components as
well as adaptations to optimize fit to the target population and VA women’s health settings. I will then develop
and refine the intervention prototype and materials with iterative feedback from partners and mentors. Aim 3: I
will conduct a randomized feasibility pilot of ROSE+ compared to usual care including standard ROSE, with
approximately 24 perinatal Veteran participants with SMI. The pilot will assess implementation outcomes,
including acceptability and feasibility; feasibility of study processes including recruitment and randomization;
and exploratory clinical outcomes. PATH TO TRANSLATION/IMPLEMENTATION: Results will inform a
subsequent multisite efficacy study, for which I will seek independent VA funding in Year 5.