Barriers to Engaging Service Members in Mental Health Care Within the U.S. Military Health System
Abstract
Objective:
Over the past decade, there has been growing recognition of the mental health consequences associated with deployment and service by military service personnel. This study examined potential barriers to mental health care faced by members of the military in accessing needed services.
Methods:
This qualitative study of stakeholders was conducted across six large military installations, encompassing 18 Army primary care clinics, within the context of a large randomized controlled trial. Stakeholders included patients recruited for the study (N=38), health care providers working within site clinics (N=31), and the care managers employed to implement the intervention protocol (N=7).
Results:
Issues raised across stakeholder groups fell into two main categories: structural factors associated with the Army medical system and institutional attitudes and cultural issues across the U.S. military. Structural issues included concerns about the existing capacity of the system, for example, the number of providers available to address the population’s needs and the constraints on clinic hours and scheduling practices. The institutional attitude and cultural issues fell into two main areas: attitudes and perceptions by the leadership and the concern that those attitudes could have negative career repercussions for those who access care.
Conclusions:
Although there have been significant efforts to improve access to mental health care, stakeholders within the military health system still perceive significant barriers to care. Efforts to ensure adequate and timely access to high-quality mental health care for service members will need to appropriately respond to capacity constraints and organizational and institutional culture.
There is growing recognition of the mental health consequences associated with deployment and service among military service personnel (1). Several studies document the prevalence of mental health problems in the military (2–5) and highlight the potential barriers that members of the military may face in accessing mental health services (6–8). As the primary source of health care for service members, the military health system (MHS) bears special responsibility in addressing these issues. With 9.6 million beneficiaries, 56 medical centers, and 360 ambulatory care clinics, the MHS represents one of the largest health systems in the United States.
Primary care has been referred to as the de facto mental health system (9–11). Over the past two decades, multiple efforts have been implemented in health systems to integrate behavioral health into primary care settings. Often referred to as “collaborative care,” the goal of these initiatives is to integrate and improve the mental health services that are delivered in primary care. Common components of these models include efforts to prepare the practice setting by training providers in behavioral health issues; use of a team approach, most often involving a care manager for engaging patients, improving their adherence to treatment, and assessing treatment response; and use of strategies to enhance the interface between specialists and primary care (12).
In the MHS, service members have an average of three encounters per year in primary care (13). There have been several attempts to integrate behavioral health services into primary care settings and line units in the MHS. In 2007, the Army began integrating mental health services into all of its primary care clinics, including the colocation of mental health specialists and the use of nurse care managers (14,15). In 2013, it expanded the assignment of trained behavioral health clinicians to line units and troop medical clinics. These efforts were intended to expand access to behavioral health specialty providers and reduce soldier concerns with seeking help. Despite these efforts, concerns about access to and quality of mental health treatment within the MHS persist (1,16).
This qualitative study was designed to understand stakeholder experiences regarding treatment of posttraumatic stress disorder (PTSD) and depression in Army primary care clinics (17). Specifically, we gathered information about participants’ experiences with barriers to accessing and utilizing mental health care within the U.S. Army. In addition to gathering insights regarding obstacles and barriers, we asked stakeholders for recommendations to increase help seeking among soldiers with mental health problems.
Methods
We conducted a series of one-on-one interviews with stakeholders within the context of a large randomized controlled trial testing the effectiveness of a centrally assisted, stepped-care model of collaborative care for PTSD and depression. The model was compared with the standard version of collaborative care offered throughout the MHS. The study was conducted across six large military installations from which service members deployed and to which they returned; together these installations housed 18 primary care clinics (17). Stakeholder groups included patients of the primary care clinics who were recruited for the study, care providers in clinics at each installation, and care managers implementing the study intervention. Patient participants were drawn from both intervention arms in the study. Procedures were approved by all relevant institutional review boards. All stakeholders who were interviewed provided oral consent for participation.
Patients
We randomly selected patients within each site to participate in up to three 30-minute interviews. We randomly drew patients’ names and contact information on a rolling basis across the one-year study enrollment period. At each site, we attempted to recruit six patients, two from each of the intervention conditions, for a total of 36 patients across the study. After sending an introductory e-mail, we contacted patients by phone to ascertain willingness to participate and schedule an interview. Of the 60 soldiers invited to participate, we were unable to reach 14, three declined participation, and five were no-shows.
Once recruited, each patient was asked to participate in up to three interviews across the one-year time span. Each of the three interviews followed the same protocol in an attempt to assess how experiences and responses evolved over time. Interviews were scheduled to occur at three time points: within approximately one to two months, four to five months, and seven to eight months of the soldier’s entrance into the study. For some patients, delays in scheduling interviews increased the interval between appointments.
All interviews were conducted over the phone by trained qualitative interviewers assisted by a notetaker. Using a semistructured interview guide, the interviewer asked about expectations regarding study participation; experiences getting care and working with their assigned care manager; use of mental health services, including barriers to or facilitators of mental health services that they experienced personally; and use of study tools and resources, for example, Web-based self-management resources, and recommendations for improving the delivery of mental health care to soldiers with PTSD or depression. Interviews were recorded and transcribed, and they lasted less than 30 minutes. Once transcripts were verified, recordings were deleted. Patients received a $25 gift card following each interview, for a potential total remuneration of $75 for participating in all three interviews.
Providers
Given the absence of centralized rosters of providers, the study site coordinators generated lists of all health care providers working within the installations’ clinics, by setting and specialty type. From these lists, the qualitative study team recruited a similar number of general medicine providers (physicians, physician assistants, and nurse practitioners) and mental health specialty providers (psychiatrists, psychologists, and social workers). For the mental health providers, we sought providers working in the primary care clinic as well as the behavioral health clinics and operational units on the installation, given that patients in the study could be receiving care in these locations as well, and they could be interacting with the care manager. The study team randomly recruited five providers per site from the lists of providers until it reached its target of 30 providers. The study team contacted 100 providers across the six sites, and interviewed 31. Providers were asked to participate in one 15- to 30-minute interview about their experiences addressing soldiers’ mental health needs; delivering behavioral health care within the MHS, including barriers to or challenges in treating soldiers with PTSD or depression in their clinic; and any specific experience related to the study. At the end of each interview, providers were asked if they had any additional thoughts they wanted to share about addressing the mental health needs of soldiers. Participating providers were given a $35 gift card for participating.
Care Managers
The seven study care managers (licensed nurses responsible for managing care of specific patients) included six who were located at a specific site and one who was centrally located and provided backup or overflow care management; six of the seven were female. They were asked to participate in two one-hour interviews about their experiences with study patients and providers. The timing of interviews was based on the study’s life cycle: one took place in the first three months of the site’s study enrollment period and one occurred in the last month of the study. The early and late interview discussion guide covered a range of topics, including experiences engaging patients into care (for example, working with the patient to set treatment goals and schedule appointments), including any barriers they have encountered in delivering services, sharing information with providers both on- and off-site, and perceptions of the specific study tools and resources they were provided—and any other comments they might have about addressing soldiers’ mental health needs. During the final interview, we also used a medical record–assisted recall approach to foster feedback on their experiences with five specific patients whose care they managed. For the assisted-recall methods, we randomly chose patients who participated in the intervention at each site, and their names were provided to the care manager at the time of the interview. All interviews were recorded and transcribed. Once transcripts were verified, recordings were deleted. Care managers were offered a $75 gift card for participating.
Analysis
All transcripts were coded by using ATLAS.ti qualitative data analysis software. A coding scheme was drafted, used to code five transcripts, checked by the analytic team, and refined and expanded. To ensure interrater reliability, another member of the team reviewed a random selection of each set of transcripts to ensure consistent application of theme categorizations. Review of interview transcripts of the same participants across their three interviews suggested that patients did not perceive changes in barriers to treatment over time but rather gradually became more engaged in care.
Results
A total of 76 stakeholders (38 patients, 31 providers, and seven study care managers) were interviewed between July 2012 and June 2014 about their experiences with receiving or delivering mental health care within the MHS. Table 1 displays demographic characteristics of the 38 patients who participated in the initial interviews; 31 (82%) completed at least two interviews, and 27 (71%) completed all three. Table 2 displays information about the 31 providers who were interviewed.
| Enhanced care (N=19) | Usual care (N=19) | Total (N=38) | ||||
|---|---|---|---|---|---|---|
| Characteristic | N | %a | N | %a | N | %a |
| Male | 13 | 68 | 12 | 63 | 25 | 66 |
| Age (M±SD) | 32±6.9 | 29±6.7 | 30±6.9 | |||
| Rank | ||||||
| Enlisted | 10 | 53 | 9 | 47 | 19 | 50 |
| Officer | 8 | 42 | 8 | 42 | 16 | 42 |
| Missing data | 1 | 5 | 2 | 11 | 3 | 8 |
| Marital status | ||||||
| Single | 9 | 47 | 11 | 58 | 20 | 53 |
| Married or living with partner | 4 | 21 | 3 | 16 | 7 | 18 |
| Separated, divorced, or widowed | 5 | 26 | 3 | 16 | 8 | 21 |
| Missing data | 1 | 5 | 2 | 11 | 3 | 8 |
a
Percentages may not add to 100% because of rounding.
| Characteristic | N | % |
|---|---|---|
| Male | 17 | 55 |
| Setting | ||
| Primary care clinic | 22 | 71 |
| Specialty clinic | 4 | 13 |
| Embedded in operational unit | 5 | 16 |
| Provider type | ||
| Behavioral health (psychologists, social workers, and psychiatrists) | 18 | 58 |
| Primary care (physician assistants, nurse practitioners, and medical doctors) | 13 | 42 |
During these discussions, 99% (N=75) of stakeholders discussed a number of issues that they perceived as inhibiting timely access to and receipt of high-quality mental health care. Issues raised across stakeholder groups fell into two main categories: structural factors associated with the system itself and institutional attitudes and cultural issues across the U.S. military.
Structural Issues
Timely receipt of mental health care is dependent not only on identifying the need for care and reaching out for help but also on whether care is available where and when it is needed. When asked about the types of challenges that got in the way of getting help or delivering services to soldiers with mental health problems, 47% (N=36) of stakeholders raised issues about the structure of the military health care system as potential barriers to delivering care. These issues included concerns about the capacity of the system, for example whether there were enough providers available to meet patients’ needs (noted by 15 [20%] stakeholders). Both patients and providers raised this issue, particularly with respect to ensuring timely access to appointments. Table 3 contains illustrative quotes of stakeholder perceptions of structural barriers to care.
| Patientsa (N=38) | Providers (N=31) | Care managers (N=7) | |||||
|---|---|---|---|---|---|---|---|
| Perception | N | %b | N | %b | N | %b | Examples |
| Limited provider capacity restricts timely access to appointments | 6 | 16 | 4 | 13 | 5 | 71 | “The workload is very high. I am new and the population of clients coming through the door is nonstop.” [BH provider] |
| “Capacity to serve the high need for care is an issue. . . . I am running out of places to send my patients. I don’t have any place to send acute patients. We need more capacity.” [PC provider] | |||||||
| “Patients are unable to get appointments, which disrupts continuity of care.” [BH provider] | |||||||
| “What we’re having is not enough appointments for the soldiers, they’re only booked once a month, so they feel like they’re not getting enough care, as much as they need.” [care manager] | |||||||
| “I just want to know what’s going on. When you’re told you may have a problem . . . I want some answers sooner than three weeks away.” [enhanced collaborative care patient] | |||||||
| “My next appointment should be in the next week, and I have an appointment every 2–3 weeks or so. If I feel like it needs to be more—they talked about referring me off-post.” [usual care patient] | |||||||
| “One month I could go to this particular care provider, and then not even a week later, I’m speaking with someone else. And it’s one of those things where the turnover rate or whatever was like super high.” [usual care patient] | |||||||
| “Some of the appointment wait times are 2–3 weeks.” [BH provider] | |||||||
| “Most PTSD clinics or Wounded Warrior clinics are full and the wait times are long.” [PC provider] | |||||||
| “Some of the challenges might be availability. We don’t have enough staff to see people on a weekly basis. We have struggled to see suicidal patients weekly. [We have seen] 800 patients last monthly 3 weeks. We have three full-time therapists and two part-time therapists.” [BH provider] | |||||||
| There are constraints on provider’s time for appointments and follow-up | 0 | — | 12 | 39 | 4 | 57 | “Another part of the issue is my time. If I had the time to make phone calls and do virtual follow [follow-up by phone or email], I would do it.” [PC provider] |
| “I have had a hard time contacting service members who work the same hours that I do.” [care manager] | |||||||
| “And every time I called back it was, ‘Oh, call back next week. Call back next week.’ Sometimes one of the big things is just the feeling I get is . . . especially if you’re trying to get the information over the phone . . . is you get the feeling that it’s not really their priority to get you.” [usual care patient] | |||||||
| “Limitations make it tough to treat PTSD. Providers have limitations in terms of duration of time and numbers of appointments. I am supposed to limit visits to four per problem. This is not set in stone. My appointments are also limited to 30 minutes.” [BH provider] | |||||||
| “In terms of appointment time, an 8- to 15-minute allotment is not enough time.” [PC provider] | |||||||
| “In addition to the large patient load and the short appointment times, the overall complexity of PTSD is the issue.” [PC provider] | |||||||
| “I think the main issue is time. The therapies are supposed to be 90 minutes long, but we don’t have time for that. Most appointments are 60 minutes. So we don’t follow that guidance.” [BH provider] | |||||||
| “We do use those evidence-based practice (EBP) skills, but we need to modify them because of the constraints of 30-minute appointments that are short-term. I modify the EBPs to help the patient.” [BH provider] | |||||||
| “As an embedded provider, we are limited in time—so we can’t spend as much time or have as many visits as we would have had we been in traditional behavioral health settings. You can request additional visits, but must get authorizations after significant justification for the ‘extra’ time. We are limited to 30–40 minute sessions.” [BH provider] | |||||||
| Work hours conflict with clinic hours | 12 | 32 | 0 | — | 0 | — | And that’s why I didn't go to like that support group that I was recommended, because it’s hard to get off work during the day and then be gone without having to make up a lie about why I’m leaving.” [usual care patient] |
| “That is a lot of it because like our unit, they don't like us—like Mondays, Wednesdays, and Fridays have pretty much [been] deemed out, you know, you can’t have appointments on these days unless they’re after hours. And, you know, just having Tuesdays and Wednesdays or, you know, trying to make an appointment on an evening, a lot of times you can’t, you know.” [usual care patient] | |||||||
| “Well since I have to now keep appointments for my assessments to get out of the Army, half the time I don’t tell them if it’s a medical appointment or one of those. So they just assume it’s one of the med board assessments, and I’m able to get off work. So I don’t really tell them what the appointment is for, and I’m able to go to it easier.” [enhanced collaborative-care patient] | |||||||
a
Patients were enrolled in a randomized controlled trial of enhanced collaborative care for PTSD and depression at six military installations. Abbreviations: BH, behavioral health; PC, primary care
b
Percentages reflect stakeholders who identified a structural barrier to mental health care.
A second structural concern included constraints on clinic hours and scheduling practices. Thirty-nine percent (N=12) of providers and 57% (N=4) of care managers spoke of the limited time available during each visit to tend to the patient’s full range of concerns. At the same time, many providers (particularly those engaged in trying to do follow-up telephone care) and care managers mentioned concerns about the overlap between their work hours and those of their patients, which made it nearly impossible to reach patients by phone during the day. In the MHS, care is such that appointments are offered only during duty hours, requiring that service members obtain permission from their supervisors or commanders to be absent from work in order to attend the appointment. As a result, their health care is subject to the varying knowledge, attitudes, beliefs, and will of their commanders, a subject that also arises below in the discussion of institutional attitudes and culture. Indeed, 32% (N=12) of patients reported inability to take time off as a barrier to care.
Institutional Attitudes and Culture
The attitudes and culture of the Army as an institution and workplace setting were among the issues identified as affecting access to care. The military ethos values “toughing it out” and espouses that persons with problems are weak. These attitudes, sometimes defined as “public stigma,” are perceived to be a major impediment to care seeking among military personnel. Stakeholders commonly cited these issues when asked about barriers to care that they had experienced. These issues broadly fell into two main areas: attitudes and perceptions of the unit (or line) leadership toward soldiers who seek mental health care and the possibility of negative career repercussions for persons who access care. Thirty-nine percent (N=15) of patients, 10% (N=3) of providers, and 86% (N=6) of care managers voiced concerns about attitudes among leaders and their willingness to allow soldiers to schedule appointments. Indeed, 39% (N=15) of patients were concerned that requesting time off for mental health visits and attending such visits would have an adverse impact on their careers, either through fewer promotion opportunities or even separation from the military. Table 4 summarizes stakeholder perceptions of institutional barriers to treatment that were related to attitudes and culture.
| Patientsa (N=38) | Providers (N=31) | Care managers (N=7) | |||||
|---|---|---|---|---|---|---|---|
| Perception | N | %b | N | %b | N | %b | Examples |
| Perceived leadership attitudes and perceptions influence soldiers’ willingness to access care | 15 | 39 | 12 | 39 | 6 | 86 | “My chain of command does not believe me either. I guess they don’t think anything is wrong with me . . . so they’re really giving me a hard time.” [enhanced collaborative care patient] |
| “The major challenge we face is really being able to ensure the soldier can get time off to attend visits and get the needed care. They have difficulty getting chain of command to allow them time off or getting excused from the field.” [PC provider] | |||||||
| “They [chain of command] give me a hard time for going to appointments. They say I always have appointments and they always want me to bring a note in, bring a note after I’m done.” [usual care patient] | |||||||
| “The command is not very willing to release patients for therapy. When soldiers are in the field, they cannot leave.” [BH provider] | |||||||
| “Sometimes I don’t think they understand the challenges that I’m facing, and there isn’t a lot of empathy for—and I guess they don’t understand the need for me to have an appointment during the work day. So it makes it very difficult. . . . I have like three appointments a month, I already get a lot of flak for that, and I’m definitely looked down upon.” [enhanced collaborative care patient] | |||||||
| “As much as they talk about getting help if you need it, they still have this tendency to portray that it’s weakness. The sergeant major in my unit has told people to stop making appointments or they can’t have any more appointments for now and to stop making appointments to get out of work.” [enhanced collaborative care patient] | |||||||
| “I have to go to [name of supervisor] all the time, and it doesn't do anything. I just want to get out because I can't do anything with that Army anymore.” [enhanced collaborative care patient] | |||||||
| “Availability is an issue. Command support for time away is another issue. Command support of behavioral health could be improved. It is variable from person to person.” [BH provider] | |||||||
| “Follow-up is good. We have good relationships with the chain of command. Our physician assistants can also follow up well.” [BH provider] | |||||||
| Accessing care may have a negative career impact | 15 | 39 | 0 | — | 6 | 86 | “They’re petrified, a lot of them, that if they tell you what’s going on, that they will be kicked out of the service, even though they’re told they’re not going to, that stigma is still there for a lot of soldiers.” [care manager] |
| “That’s why most of the time they just don’t say anything. Because they’re afraid that, because of the downsizing, that they’ll be—end up getting chaptered out.” [care manager] | |||||||
| “And you don’t want to tell your boss that you have an appointment for something behavioral health. You like to hide those problems. I feel that I look inferior if I, you know—I just like to tell them, hey, I have this issue and I'm dealing with it. But if I, you know, have to bring it up every couple weeks to say I have an appointment—I have to go here for this–you don't want it that visible. You want to look like you can always do your job, no matter what.” [enhanced collaborative-care patient] | |||||||
| “I can’t receive the treatment that I need because of my job. So it comes down to a point where I can choose my professional career and what supports my family or what I actually need. And it’s sad that it’s like that.” [usual care patient] | |||||||
| “I don’t want to tell my boss that, ‘Hey, I got a counseling appointment.’ You just always want to appear that you can do everything and you don’t need help. I think maybe they just wouldn’t look at me the same. It’s one thing to say—because I had to tell my boss that I have a problem going into the OR. I got a little PTSD stuff going on with that. And it’s one thing to tell her that and, ‘Hey, I’m trying to work on it; I’m getting a little counseling.’ It’s another to go up every week or two and say, ‘Hey, I got to go for an appointment. I’m leaving a few hours early.’ I think you just don’t look quite as competent, not as self-sufficient, you know?” [enhanced collaborative care patient] | |||||||
a
Patients were enrolled in a randomized controlled trial of enhanced collaborative care for PTSD and depression at six military installations. Abbreviations: BH, behavioral health; PC, primary care
b
Percentages reflect stakeholders who identified a structural barrier to mental health care.
Recommendations for Improving Access and Receipt of Care
During each interview, we asked for suggestions on how to improve access to mental health care for soldiers. All patients, all care facilitators, and one-quarter of providers offered at least one suggestion. Among the 52 stakeholders who made a recommendation, 75% (N=39) called for expanding access for soldiers and their families to resources available off the installation. Soldiers mentioned not only that community resources were available but also that such resources were often preferred because they were perceived to offer a greater likelihood of confidentiality and because they were available outside work hours. Other suggestions included addressing the attitudes of leadership directly through targeted training programs—25% (N=13) of stakeholders commented that military leaders needed to become more aware of mental health challenges and issues facing soldiers and to be taught how to be more empathic and to facilitate soldiers’ receipt of care. Others mentioned a need to encourage providers to communicate directly with command when there was a lack of support for service members in keeping their appointments. Table 5 lists recommendations for encouraging help seeking.
| Patientsa (N=38) | Providers (N=7) | Care managers (N=7) | |||||
|---|---|---|---|---|---|---|---|
| Recommendation | N | %b | N | %b | N | %b | Examples |
| Expand access to off-post resources | 31 | 82 | 2 | 29 | 6 | 86 | “The only thing I’d think of is if there would be a way that they could either contract out to civilian doctors off-post or something like that. That way they would be able to lower the caseload and not have to wait a month, month-and-a-half, for your next appointment.” [enhanced collaborative care patient] |
| “I think it’d be easier to have more stuff [we] can do outside of work . . . as well as having places that you can go outside of work . . . so having an option to go to after duty hours or on weekends or something like that would be nice.” [enhanced collaborative care patient] | |||||||
| “[Off-post provider] has been a lot better and talking to [my care manager] on the phone has been good enough. I don’t think he [off-post provider] comes from [a perspective of] defending the military and telling me that it’s OK what they are doing to me. He’s not like the lady I was seeing who was military. He listens to how I feel and helps me cope with it better. He’s not telling me how they [the military] see it or trying to make me change my opinion. I can tell him exactly what’s on my mind and how I feel without him telling me that I knew that when I joined or that’s how it is.” [enhanced collaborative care patient] | |||||||
| “I would say the only thing would be to work on not having it [be] so difficult to go to a civilian provider. The process of having to go on-post for X amount of visits before you can get a referral to go see somebody else is kind of ridiculous, because if you have somebody like me—like if I could have I would have gone off-post immediately because I don’t want to have anything to do with the on-post counselors because of the generalization and the ‘stigmatism’ that carries. I would have gone off post originally. But a lot of times that isn’t a very easy option.” [usual care patient] | |||||||
| “It’s worlds different. I think the thing with on-post is they just, in their mind, they already have an agenda and they already think they know what you're going to say. So I felt like they anticipate because they already have it all figured out what you’re going to say and what their prognosis or diagnosis of you is and what they think about you. They already have all that planned out before you even start talking to them.” [usual care patient] | |||||||
| Provide better training for leadership | 9 | 24 | 3 | 43 | 1 | 14 | “The leaders need more training on how to deal with us. They need more training on how not to call us out about our issues or call[ing] us weak. I think they need training because the ones saying these things need help themselves. I think training the leaders is the first step and then training the soldiers with the families is important too.” [enhanced collaborative care patient] |
| “Educate commands to encourage their soldiers to go get help. Or even bring in—I know when I was in my first tour, we had somebody come in one day when the whole group was there and just kind of give us an overall kind of class on, you know, different things that could have been going on and just kind of a gateway to, OK, well, that’s going on in my life. Maybe I should set up an appointment.” [enhanced collaborative care patient] | |||||||
| “It has to start from the top. It has to be something from way high up to come down to say, ‘Hey, this is [name of superior]’—you know, they—pretty much they have to figure out how to make the units—at the highest level, make the lowest level [unit leaders] understand that something’s got to be done in certain situations or [telling them that] needing help is OK.” [usual care patient] | |||||||
| “The better the chain of command is with their support, the easier it is for the soldiers to make them want to go to it—or not make them—encourage them to go to these services that the Army has available.” [enhanced collaborative care patient] | |||||||
| Encourage communication between providers and command | 4 | 11 | 3 | 43 | 1 | 14 | “I feel like—like if I had an appointment tomorrow and I feel like one of the people, providers should have one of these nurses or somebody send out an e-mail to my chain of command, be like [name of soldier] has an appointment tomorrow. Please allow [the soldier] to come, or something like that.” [usual care patient] |
| “Maybe send a letter out to them [leadership or command] explaining what the program is about and stuff like that because I don't think anybody really knows about [this program] unless you go through [the medical clinic] and stuff like that. Like all they know about is behavioral health. They don't have any idea about STEPS-UP.” [enhanced collaborative care patient] | |||||||
a
Patients were enrolled in a randomized controlled trial of enhanced collaborative care for PTSD and depression at six military installations (STEPS-UP).
b
Percentages reflect stakeholders who identified a structural barrier to mental health care.
Discussion
Ensuring access to mental health services for U.S. service members has been the focus of several national efforts, including a presidential executive order (18). The Department of Defense and each of the military services have implemented many programs designed to raise awareness about the mental health issues associated with deployment, promote help seeking, and expand workforce capacity to meet demand for mental health services (19). Our findings reveal that despite these efforts, many stakeholders still perceive and experience significant barriers to care. Our study found significant overlap among patients seeking access to mental health care within the Army medical system and those responsible for providing or facilitating such care with respect to the obstacles and challenges faced by soldiers when trying to get help for mental health concerns.
Prior studies of barriers to mental health care among civilian populations often identify concerns about affordability and effectiveness of care (8). Many studies have suggested that the greatest barrier to receiving and remaining in care for military personnel was related to stigma among soldiers (5,8,20,21), and we found evidence of this issue among all of our stakeholders. However, even more frequently, stakeholders raised concerns about structural aspects of the Army medical system as well as about the institutional culture of the Army (8). Structural issues may be easier to change than cultural attitudes, yet they persist in spite of many efforts to facilitate access to mental health services and support (19). All of the service members in our study had a mental health problem and were assigned to a care manager to help them navigate care and obtain needed appointments. Yet these stakeholders noted significant structural and organizational barriers to securing timely care.
Both patients and providers perceived a shortage of professionals and expressed frustration over the resulting long wait times for appointments. Providers also noted that the short visit times limited their ability to attend to all of the patient’s concerns, including those related to mental health. Addressing these concerns will involve considering structural changes to improve the systems of mental health service delivery, such as hiring more mental health providers, expanding access to off-post mental health providers, lengthening the time allotted for primary care sessions, and expanding clinic hours to offer appointments during evenings and weekends.
Both patients and providers also noted that attitudes among Army leaders toward help seeking, particularly attitudes that discourage getting help and promote the “tough it out” ethos, were a significant barrier for soldiers who needed or wanted help. A handful of other studies have also documented the influence of poor leadership not only on the experience of postdeployment mental health problems (22) but also on stigma and soldier help seeking (5,8,20,21). Britt and others (23) found that leaders who engaged in negative behaviors, such as embarrassing unit members in front of others, were more likely to create work environments conducive to higher levels of stigma concerning mental health care among their soldiers. Our stakeholders reported that getting approval to leave work and attend appointments may be intimidating, and many feared that there could be adverse career repercussions if they did so. Britt and colleagues (23) also observed that leaders who engaged in more positive behaviors were more likely to make accommodations for individuals who sought treatment. In a 2013 study of active duty soldiers, Zinzow and colleagues (8) noted that leadership attitudes and behaviors were critical as both potential barriers to and facilitators of treatment seeking.
Taken together, these findings suggest that improving military leaders’ attitudes about mental health may be important for facilitating help seeking. Given the multiple levels of leadership within the military, these efforts need to include senior, mid-grade, and junior officers to ensure that they reach all of the microcultures within the overall military command climate. Within the first-responder community, other agencies have implemented Psychological First Aid for Leaders to change how leaders understand and respond to individuals who experience mental health issues (www.phe.gov/abc). This course may serve as a model for the Department of Defense as it continues to address barriers to mental health treatment among service members and promote more supportive work environments.
A few study limitations should be noted. Specifically, our data were collected from patients who had successfully overcome some of the barriers and who sought care at relatively large installations with robust care systems. As such, their concerns may underrepresent the magnitude and scope of barriers facing service members in other settings, including those at smaller military installations. Furthermore, these data were collected from within Army clinics, and it is unclear to what extent the same issues would be identified among patients in clinics managed by other service branches. However, we expect that regulatory tensions between the military unit and persons seeking military medical care are likely to remain qualitatively similar across branches of service. Finally, few study participants sought care outside the MHS and, therefore, did not discuss barriers they might face in the civilian service sector. There has also been a proliferation of civilian provider networks that serve service members, veterans, and their families. As such, whether service members face similar barriers within those systems has yet to be evaluated.
Conclusions
Military service, particularly during a period of active combat, is arguably one of the most stressful occupations. Given added concerns about trauma exposures, both before and after service and deployment, there is sound basis to enhance access to mental health services for service members. The issues and concerns regarding the role of the leadership and commanders in influencing service members’ willingness and ability to seek such care are of significant concern. Commanders are often regarded as members of the care team, and they have unusual access to medical records (24). These factors suggest a need to reexamine commanders’ roles around mental health service delivery and to ensure that they are facilitators of and not barriers to the mental health care needed by their troops.
Footnote
The sponsor of this study had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The views expressed in this article are those of the authors and do not necessarily represent the views of the U.S. Department of Veterans Affairs, the Department of Defense, or a U.S. government agency.
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Information & Authors
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Cover: Anniversary Tin: Candelabra, anonymous artist, ca. 1880–1900. Tin with sand-weighted base. Collection American Folk Art Museum, New York City. Gift of Mr. and Mrs. James D. Clokey, III, 1984.29.1A. Photo: John Parnell. Photo credit: American Folk Art Museum, Art Resource, New York City.
History
Received: 15 June 2015
Revision received: 14 September 2015
Accepted: 16 November 2015
Published online: 15 March 2016
Published in print: July 01, 2016
Authors
Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
Department of Defense Deployment Related Medical Research Program: W81XWH-09-2-0079
This study was supported by a Department of Defense Deployment Related Medical Research Program award (grant DR080409; award W81XWH-09-2-0079).Metrics & Citations
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