Barriers to Care

Barriers to Care

Introduction

The Defense Department (DoD) strives to better understand the barriers to care service members face regarding mental health diagnoses and treatment. Barriers to care include personal barriers such as perceived stigma and negative beliefs about mental health treatment.

Stigma

In the last decade, DoD has focused significant attention and resources on reducing mental health stigma in the military. While research indicates that mental health stigma remains a significant concern for service members, particularly those in need of mental health treatment, there are mixed findings about how it impacts treatment seeking or mental health service use[3],[4]. Rates of perceived stigma among service members have consistently been problematic. In response, DoD has sustained efforts to reduce mental health stigma including campaigns and programs.

In the military, stigma is often conceptualized in the context of seeking mental health treatment and perpetuated by service members in response to “(1) public stigma - the public (mis)perceptions of individuals with mental illnesses; (2) self-stigma – individuals’ perceptions of themselves; and (3) structural stigma – institutional policies or practices that unnecessarily restrict opportunities because of psychological health issues”[5]. Stigma may prevent service members from seeking timely treatment for their mental health disorders.

Research indicates that those who are seeking mental health treatment often note much higher rates of stigma than those not seeking treatment. Common concerns of service members about seeking mental health care include[6]:

  • Impact on career
  • Negative view from peers and commanders
  • Being treated differently (unit members have less confidence in abilities)
  • Lack of confidentiality
  • Appearing weak
  • Treatment effectiveness (“I can/should handle it on my own,” friends and family may be more effective in helping) [7]
  • Lack of trust in military health care[8]

In the 2011 DoD Health Related Behaviors Survey of Active Duty Military Personnel, which is the largest survey that anonymously gathers data on some of the most important behavioral health issues affecting the well-being of the U.S. military, “over one-third (37.7 percent) indicated that seeking help would damage a person’s military career, with Navy personnel most often perceiving stigma for help-seeking (42.1 percent) compared to other services.” Of those individuals who did receive mental health treatment, 21.3 percent believed it negatively affected their career.

Researchers have found there are several factors that have a positive impact on reducing stigma[9]:

  • Resilience
  • Unit cohesion
  • Positive leadership environment
  • Positive experiences with mental health providers
  • Social support (family and friends) encouragement

What Providers Can Do to Reduce Stigma

  • Encourage family and friends to support service members seeking help[10]
  • Research indicates that effective leadership is associated with less perceived stigma among service members[11]. Work with military leadership to encourage an open dialogue about mental illness and mental health resources; help leaders promote good communication between team members. Encourage leaders to promote unit support for seeking mental health treatment[12]
  • Counter inaccurate stereotypes and misperceptions about mental illness with accurate facts. Educate service members about mental illness and encourage them to seek out accurate portrayals (e.g. Real Warriors Campaign). It is also important to educate clinic staff to dispel myths that mental illness is dangerous and unchangeable[13]
  • Counter inaccurate perceptions about mental health care
  • Promote positive attitudes about mental illness and recovery
  • Encourage integration of mental health services in primary care to reduce stigma[14]

Health Beliefs

Personal negative attitudes about mental health and mental health treatment is another area believed to be a barrier to care. A lack of trust in mental health providers as well as the mental health care system can impede service members from obtaining the treatment they need[15]. Research found that personal beliefs about mental illness and health treatment may be related to use of mental health services[16]. Many service members reported that they believed their treatment was ineffective[17]; they were concerned about the side effects of psychotropic medications[18]; and they felt they could take care of the problem on their own[19]. Concerns about logistics including getting time off work for treatment, the cost of health care, and difficulty scheduling an appointment were also noted, particularly in service members who screened positive for a mental health disorder[20].

Treatment Drop Out

In a recent study, two-thirds of soldiers diagnosed with posttraumatic stress disorder (PTSD) who did not complete treatment noted that it was due in part to “discomfort with the interpersonal interaction with the mental health provider, including the perception that the provider was not suitably caring, communicative, or competent”[21]. Hoge and colleagues (2014) suggest that negative attitudes about treatment may outweigh stigma as a reason for dropping out of treatment. Other common reasons patients reported for dropping out of treatment included:

  • Felt they could take care of problems on their own
  • Too busy with work
  • Did not feel comfortable with the mental health provider
  • Did not have sufficient time with the mental health provider

Each service has its own satisfaction survey relating to medical care received through both direct care and TRICARE services. While there are barriers to care, the majority of survey respondents report receiving needed care and are satisfied with the care. Specifically, from 2012 to the first quarter of 2014, approximately 85 percent of survey respondents stated that they received care when needed[22] and about 70 percent were satisfied with “seeing a provider when needed.”

Help-seeking Behavior

Researchers continue to examine how service members cope with stress. In an attempt to avoid associating themselves with mental health and mental health issues, service members often seek out help from other sources first. Data from the 2011 Health Related Behaviors Survey of Active Duty Military Personnel, noted that in the previous 12 months, over 25 percent of military personnel perceived a need for mental health counseling. Other ways in which service members reported coping with stress can be found in the table.

Table: 2011 Health Related Behaviors Survey of Active Duty Military Personnel

Note: Table displays the percentage of military personnel, by service, who reported using the indicated stress coping behaviors “frequently” or “sometimes.” The standard error of each estimate is presented in parentheses.

Coping Behavior Army Navy Marine Corps Air Force Coast Guard All Services
Talking to a Friend/Family Member 71.8 (0.8)c,e 74.2 (0.7)c 66.3 (0.8)a,b,d,e 73.7 (0.5)c 75.2 (0.7)a,c 72.2 (0.4)
Light up a Cigarette 23.2 (0.7)c,d,e 20.8 (0.7)c,d,e 28.3 (0.7)a,b,d,e 14.3 (0.4)a,b,c,e 17.0 (0.6)a,b,c,d 20.9 (0.3)
Have a Drink of Alcohol 24.1 (0.7)c,d 25.1 (0.7)c,d 32.8 (0.8)a,b,d,e 15.6 (0.4)a,b,c,e 25.0 (0.7)c,d 23.4 (0.3)
Say a Prayer 46.1 (0.9)c,e 44.3 (0.8)c 38.2 (0.8)a,b,d 45.3 (0.5)c,e 41.3 (0.8)a,d 44.3 (0.4)
Exercise or Play Sports 61.7 (0.8)b,c,d,e 67.3 (0.8)a 66.6 (0.8)a,e 69.2 (0.5)a 70.2 (0.7)a,c 65.7 (0.4)
Engage in a Hobby 65.9 (0.8)d 64.8 (0.8)d,e 63.4 (0.8)d,e 68.6 (0.5)a,b,c 68.1 (0.8)b,c 66.1 (0.4)
Get Something to Eat 46.2 (0.9)d 46.9 (0.8)d,e 44.3 (0.8)d 39.4 (0.5)a,b,c,e 43.6 (0.8)b,d 44.3 (0.4)
Some Marijuana/Use other Illegal Drugs 0.4 (0.1)c 0.6 (0.1)d 1.2 (0.2)a,d,e 0.2 (0.1)b,c 0.5 (0.1)c 0.5 (0.1)
Think of a Plan to Solve Problem 87.3 (0.6)c 86.1 (0.6)e 83.8 (0.6)a,e 85.7 (0.4)e 88.7 (0.5)b,c,d 86.2 (0.3)
Think About Hurting or Killing Myself 3.4 (0.3)c,d,e 3.2 (0.3)c,d 5.0 (0.4)a,b,d,e 1.5 (0.1)a,b,c 2.2 (0.2)a,c 3.0 (0.1)
Sleep 51.2 (0.9) 53.5 (0.8)d,e 52.0 (0.8)d 48.4 (0.5)b,c 48.8 (0.8)b 51.0 (0.4)
Get Angry 51.5 (0.9)b,c,d,e 48.1 (0.8)a,c,d,e 55.6 (0.8)a,b,d,e 34.7 (0.5)a,b,c,e 44.1 (0.8)a,b,c,d 46.9 (0.4)
Spend Time by Myself 73.6 (0.8)b,c,d,e 70.2 (0.8)a,d 69.7 (0.8)a,d 66.7 (0.5)a,b,c 68.2 (0.8)a 70.5 (0.4)

 1 Significance tests were conducted between all pairs of services. A superscripted letter beside an estimate indicates the estimate is significantly different from the estimate that appears in column #1-5. In other words:

a Indicates estimate is significantly different from the estimate in column #1 (Army) at the 95% confidence level after Bonferroni adjustment.

b Indicates estimate is significantly different from the estimate in column #2 (Navy) at the 95% confidence level after Bonferroni adjustment.

c Indicates estimate is significantly different from the estimate in column #3 (Marine Corps) at the 95% confidence level after Bonferroni adjustment.

d Indicates estimate is significantly different from the estimate in column #4 (Air Force) at the 95% confidence level after Bonferroni adjustment.

e Indicates estimate is significantly different from the estimate in column #5 (Coast Guard) at the 95% confidence level after Bonferroni adjustment.

Source: 2011 Health Related Behaviors Survey of Active Duty Military Personnel (Stress Coping Behaviors, Q122).

References

[3],[4] Acosta, J., Becker, A., Cerully, J.L., Fisher, M.P., Martin, L.T., Vardavas, R., Slaughter, M.E., & Schell, T. (2014). Mental Health Stigma in the Military. Santa Monica CA: RAND Corporation.
Sharp, M., Fear, N.T., Rona, R.J., Wessely, S., Greenberg, N., Jones, N., & Goodwin, L. (2015). Stigma as a Barrier to Seeking Health Care Among Military Personnel With Mental Health Problems. Epidemiologic Reviews, 37, 144-162.
Vogt, D., Fox, A.B., & Di Leone, B.A. (2014). Mental health beliefs and their relationship with treatment seeking among U.S. OEF/OIF veterans. Journal of Traumatic Stress, 27,1-7.

[5]Sammons, M. T. (2005). Psychology in the public sector: Addressing the psychological effects of combat in the U.S. Navy. American Psychologist, 60(8), 899-909.

[6] Office of the Surgeon General United States Army Medical Command, Office of the Command Surgeon Headquarters, US Army Central Command (USCENTCOM), & Office of the Command Surgeon US Forces Afghanistan (USFOR-A). (10 October 2013). Mental Health Advisory Team 9 Operational Enduring Freedom (OEF) 2013 Afghanistan. Retrieved from http://armymedicine.mil/Documents/MHAT_9_OEF_Report.pdf.
National Council on Disability. (4 March 2009). Invisible Wounds: Serving Service Members and Veterans with PTSD and TBI. Retrieved from http://www.ncd.gov/publications/2009/March042009/
Institutes of Medicine (26 March 2013). Returning Home from Iraq and Afghanistan: Readjustment Needs of Veterans, Service Members, and Their Families. Retrieved from http://www.nationalacademies.org/hmd/Reports/2013/Returning-Home-from-Iraq-and-Afghanistan.aspx
Sharp, M., Fear, N.T., Rona, R.J., Wessely, S., Greenberg, N., Jones, N., & Goodwin, L. (2015). Stigma as a Barrier to Seeking Health Care Among Military Personnel With Mental Health Problems. Epidemiologic Reviews, 37, 144-162.

[7] Cozza, S.J., Goldenberg, M.N., & Ursano, R.J. (eds). (2014). Care of military service members, veterans and their families. Arlington, VA: American Psychiatric Association.

[8] Cozza, S.J., Goldenberg, M.N., & Ursano, R.J. (eds). (2014). Care of military service members, veterans and their families. Arlington, VA: American Psychiatric Association.

[9] Office of the Surgeon General United States Army Medical Command, Office of the Command Surgeon Headquarters, US Army Central Command (USCENTCOM), & Office of the Command Surgeon US Forces Afghanistan (USFOR-A). (10 October 2013). Mental Health Advisory Team 9 Operational Enduring Freedom (OEF) 2013 Afghanistan. Retrieved from http://armymedicine.mil/Documents/MHAT_9_OEF_Report.pdf.
National Council on Disability. (4 March 2009). Invisible Wounds: Serving Service Members and Veterans with PTSD and TBI. Retrieved from http://www.ncd.gov/publications/2009/March042009/
Institutes of Medicine (26 March 2013). Returning Home from Iraq and Afghanistan: Readjustment Needs of Veterans, Service Members, and Their Families. Retrieved from http://www.iom.edu/Reports/2013/Returning-Home-from-Iraq-and-Afghanistan.aspx
Sharp, M., Fear, N.T., Rona, R.J., Wessely, S., Greenberg, N., Jones, N., & Goodwin, L. (2015). Stigma as a Barrier to Seeking Health Care Among Military Personnel With Mental Health Problems. Epidemiologic Reviews, 37, 144-162.

[10] Warner, C.H., Appenzeller, G.N., Mullen, K., Warner, C.M., Grieger, T. (2008). Soldier attitudes toward mental health screening and seeking care upon return from combat. Military Medicine, 173,6,563-569.

[11] Office of the Surgeon General United States Army Medical Command, Office of the Command Surgeon Headquarters, US Army Central Command (USCENTCOM), & Office of the Command Surgeon US Forces Afghanistan (USFOR-A). (10 October 2013). Mental Health Advisory Team 9 Operational Enduring Freedom (OEF) 2013 Afghanistan. Retrieved from http://armymedicine.mil/Documents/MHAT_9_OEF_Report.pdf.

[12] Britt, T.W., Wright, K.M., & Moore,. D. (2012). Leadership as a predictor of stigma and practical barriers toward receiving mental health treatment: a multilevel approach. Psychological Services, 9,1,26-37.

[13] Cozza, S.J., Goldenberg, M.N., & Ursano, R.J. (eds). (2014). Care of military service members, veterans and their families. Arlington, VA: American Psychiatric Association.

[14] Cozza, S.J., Goldenberg, M.N., & Ursano, R.J. (eds). (2014). Care of military service members, veterans and their families. Arlington, VA: American Psychiatric Association.

[15] Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., & Koffman, R.L. (2004).Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 1, 13-22.
Kim, P.Y., Thomas, J.L., Wilk, J.E., Castro, C.A., Hoge, C.W. (2010). Stigma, barriers to care, and use of mental health services among active duty and National Guard soldiers after combat. Psychiatric Services, 61,6, 582-588.

[16] Vogt, D., Fox, A.B., & Di Leone, B.A. (2014). Mental health beliefs and their relationship with treatment seeking among U.S. OEF/OIF veterans. Journal of Traumatic Stress, 27,1-7.

[17] Hoge, C.W., Grossman S.H., Auchterlonie, J.L., Rivere, L.A., Milliken, C.S., & Wilk, J.E. (2014). PTSD Treatment for soldiers after combat deployment: Low utilization of mental health care and reasons for drop out. Psychiatric Services, 65,8, 997-1004.

[18] Vogt, D., Fox, A.B., & Di Leone, B.A. (2014). Mental health beliefs and their relationship with treatment seeking among U.S. OEF/OIF veterans. Journal of Traumatic Stress, 27,1-7.

[19] Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., & Koffman, R.L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 1, 13–22.

[20] Kim, P.Y., Thomas, J.L., Wilk, J.E., Castro, C.A., Hoge, C.W. (2010). Stigma, barriers to care, and use of mental health services among active duty and National Guard soldiers after combat. Psychiatric Services, 61,6, 582-588.

[21] Hoge, C.W., Grossman S.H., Auchterlonie, J.L., Rivere, L.A., Milliken, C.S., & Wilk, J.E. (2014). PTSD Treatment for soldiers after combat deployment: Low utilization of mental health care and reasons for drop out. Psychiatric Services, 65,8, 997-1004.

[22] Military Health System Review-Final Report