by Michael D. Anestis, M.S.
Today is a day to honor those who have chosen to serve their country through military service. The mental health care needs of military personnel have become a very prominent interest of mine in recent years and I have been privileged to work with talented members of that community (e.g., Craig Bryan, Chad Morrow) as well as my colleagues at Florida State University (e.g., Thomas Joiner, Eddie Selby, Ted Bender) in developing a better understanding of the situation and what we can do to help. Today, I wold like to express my gratitude for the service of others by discussing several studies involving Charles Hoge of Walter Reed Army Institute of Research and his colleagues on the mental health needs of soldiers, obstacles that keep them and their families from seeking out the care they need, and potential solutions for the situation.
The role of stigma and barriers to care
Acknowledging that mental health difficulties exist within samples of military personnel returning from deployment overseas is important, but it does not tell the entire story. An additional point to consider is that many individuals in need of mental health care never seek treatment. A number of reasons exist that explain that situation, but two that have been subject to growing research attention are stigma and barriers to care. In a study published in 2004 in the New England Journal of Medicine by Charles Hoge and colleagues examined these factors in a sample of 2,530 members of US combat units prior to deployment to Iraq and a sample of 3,671 US combat units three to four months after returning from combat duty in Iraq or Afghanistan. In addition to finding substantially elevated rates of numerous diagnoses (e.g., depression, generalized anxiety disorder, PTSD), the authors found that individuals who met criteria for a mental illness were substantially more likely than those who did not meet criteria for a mental illness to report a belief in a stigma and barriers associated with seeking mental health care. In other words, the individuals who actually needed care were the ones most likely to see treatment as stigmatizing and unavailable.
In a factor analysis examining the degree to which stigma and barriers to care are actually separate concepts, the Wright, Cabrera, Bliese, Adler, and Hoge (2009) confirmed that this was the case and described a screening measure that was effectively utilized to assess these variables in military personnel. The stigma subscale consisted of eight items whereas the barriers to care subscale consisted of three. The items were as follows:
Stigma
- It would be too embarrassing
- It would harm my career
- Members of my unit might have less confidence in me
- My unit leadership might treat me differently
- My leaders would blame me for the problem
- I would be seen as weak
- My visit would not remain confidential
- An office or NCO should not be in a leadership position if he/she is taking medication for a mental health problem
Barriers to care
- I don't know where to get help
- I don't have adequate transportation
- It is difficult to schedule an appointment
Given that the Hoge et al (2004) study revealed that individuals with mental health difficulties are the most likely to score highly on screening measures such as this, clearly this means that we have a situation in which those in need of help feel guilty about their struggles, believe that seeking help will cause them more harm than good, see their mental health difficulties as a weakness or believe others will see them that way, and have a hard time even accessing care in the first place. Obviously, this is not ideal and it is extremely upsetting to think that, in addition to the pain of mental illness, many soldiers also carry around the burden of the types of thoughts listed in this screening measure.
In a later study, published in the Journal of Social and Clinical Psychology by researchers at Clemson University and the Walter Reed Army Institute of Research (Britt et al., 2008), the authors examined both a sample of university students and a sample of US army soldiers in an effort to better understand the implications of stigma and barriers to care. In the university sample, they found that the relationship between stress and depression was strongest for individuals who perceived a stigma associated with seeking treatment. In other words, stress is always a predictor of depression, but it is particularly likely to lead to depression when the stressed individual believes that seeking treatment would be perceived poorly or would represent a weakness on their part. In the military sample, the authors found that the relationship between stress and depression was strongest for individuals who perceived barriers to seeking care. In other words, stress was particularly strongly related to the onset of depression in individuals who felt that they did not have adequate access to care. So, not only have we discovered that the individuals most in need of care are the ones most likely to perceive stigma and barriers to seeking treatment, we also have found that stigma and barriers to care amplify the impact of stress on the onset of mental illness. Quite clearly, a situation has developed in which those in need of mental health services have to overcome a number of obstacles - some based on life circumstances and others based on distorted beliefs - just to get into treatment in the first place.
Another recent study by Eaton and colleagues (2008) extended this conversation to include the spouses of soldiers. They found that spouses of soldiers experienced rates of mental illness that were comparable to the soldiers themselves. Additionally, although a substantial number of spouses of soldiers reported concerns regarding stigma and barriers to care, they were more likely than the soldiers themselves to seek mental health care and perceived less stigma and fewer barriers than did the soldiers. The obvious positive of this finding is the fact that stigma and barriers are reduced in spouses relative to soldiers and that help seeking behaviors were more prominent; nonetheless, the obvious negative is that a substantial degree of stigma and barriers to care were still present in this population.
What can be done to increase access to care?
In the Wright et al (2009) study mentioned above, the authors also examined factors that predicted greater help seeking behavior and better perceptions of access to care. What they found was quite promising. Not only did enhanced officer leadership and unit cohesion predict lower perceived stigma and decreased barriers to care, this prediction remained significant even when controlling for the severity of mental illness in the unit's personnel. In other words, with strong leadership and a cohesive unit, the resulting supportive environment can often override the relationship between symptom severity and perceptions of stigma and barriers to care. The importance of a finding like this would be difficult to overstate, as it appears to offer a strong target for preventative care. By enhancing the leadership approaches of officers and working on unit cohesion, the harmful relationship between developing symptoms of mental illness and perceiving problems associated with mental health care can be undercut, thereby enhancing the likelihood that soldiers who need help will have access to trained clinicians and utilize their resources.
Obviously this is not enough and not every solider in a cohesive unit with strong leadership will have access to and seek the care they need. That being said, it is an important beginning. An additional angle that researchers are taking to battle this issue is the development of a better understanding of the ideal timing for mental health assessments in post-deployment personnel. In a study published in the Journal of the American Medical Association (JAMA) by Milliken, Auchterlonie, and Hoge (2007), the authors took a longitudinal glance at the development of mental health symptoms in the months following reintegration to civilian life post-deployment. Soldiers were screened for mental health related concerns immediately upon return from deployment to Iraq as well as three to six months later. They reported several meaningful findings, including:
- 20.3% of active soldiers and 42.4% of reserve component soldiers were identified as needing mental health services
- Interpersonal conflicts increased substantially between the two assessments
- A large number of soldiers expressed concerns regarding their use of alcohol, but few were referred for help with the behavior
- More soldiers were identified as meeting criteria for PTSD at the follow-up assessment (post-deployment health re-assessment; PDHRA) than at the initial screening (post-deployment health assessment; PDHA).
- Those who were identified as suffering from PTSD at the PDHA saw significant symptom improvement between assessments.
The authors noted three particularly important aspects of these findings. First of all, when mental illnesses are identified at screening, symptoms do seem to improve. This indicates that effective treatments are, in fact, being used when clients are effectively identified and referred to treatment. Secondly, given the increase in interpersonal conflicts, services for family members of returning soldiers appear to be inadequate. Third, symptoms of mental illness in soldiers may not be evident immediately upon returning from overseas deployment or the current screening measures might not be sensitive to these symptoms as they appear at that time. This is consistent with the findings of Bliese, Wright, Adler, Thomas, and Hoge (2007), who found that symptoms of mental illness tend to be higher 120 days post-deployment relative to immediately after reintegration. As such, the most effective screening approach might involve multiple assessments spread out across the initial months of reintegration. Such a system might allow for earlier detection and a greater degree of referrals for treatment. That being said, in order for this to work, stigma and barriers to care must be addressed.
Some concluding thoughts
As we think about our veterans today, I hope many of you will take note of the fact that many soldiers are suffering in silence. For some, this means that fear the implications of seeking treatment. For others, this means that effective treatment is, for one reason or another, not easily accessible. For others, a host of other reasons explain the gap between rates of mental illness and rates of help seeking behavior. In addition to the strong efforts by the military to address these issues, a vital consideration for all of us is the need for accurate education on a large scale and the implementation of effective treatments. There is a sea of empirical research out there on mental illness and psychotherapy. We know a tremendous amount about how mental illnesses impact individuals and how to go about treating them in an efficient and long-lasting manner. Unfortunately, much of that knowledge is limited to people who spend their lives researching it and, as a result, many of those in need are unaware of all the help that is available. Fortunately, the VA system places a heavy emphasis on the utilization of empirically supported treatments (e.g., cognitive processing therapy and prolonged exposure for PTSD), but we need to help as many people learn about this information as possible, so they can readily and accurately identify when they or their loved ones need help and then know where to turn to find treatment that actually works. Soldiers sacrifice so much for us - we owe it to them to ensure that they receive the right care when they return.
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If you would like to learn more about empirically supported treatments for PTSD, we recommend the following items, all of which are available through our online store of scientifically-based psychological resources:
- Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide by Edna Foa, Elizabeth Hembree, and Barbara Rothbaum
- Prolonged Exposure Therapy for Adolescents with PTSD Emotional Processing of Traumatic Experiences, Therapist Guide
by Edna Foa, Kelly Chrestman, and Eva Gilboa-Schechtman
- Cognitive Processing Therapy for Rape Victims: A Treatment Manual
by Patricia Resick and Monica Schnicke
- Reclaiming Your Life from a Traumatic Experience: A Prolonged Exposure Treatment Program Workbook
by Barbara Rothbaum, Edna Foa, and Elizabeth Hembree
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
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