Help-seeking in Vietnam veterans: post-traumatic stress disorder and other predictors

Enablers and barriers to military veterans seeking help for mental health and alcohol difficulties: A systematic review of the quantitative evidence

OBJECTIVE

Research exploring the enablers and barriers that exist for military veterans seeking to address their poor mental health has produced ambiguous results. To identify the enablers and barriers correctly, this study systematically reviews the literature, including research that included alcohol and had a clearly defined veteran population.

METHODS

Six databases were searched. Inclusion criteria specified that empirical studies related to veterans that had ceased military service and were seeking help for poor mental health and/or alcohol difficulties. Critical Appraisal Skills Programme and AXIS appraisal tools were used to assess quality and bias. A narrative synthesis approach was adopted for analysis. From 2044 studies screened, 12 were included featuring 5501 participants.

RESULTS

Forty-four enablers and barriers were identified, with thirty-two being statistically significant. Post-traumatic stress disorder had the greatest number of enabler/barrier endorsements to veterans seeking help. Depression, anxiety, experience and attitudes also acted as enablers/barriers. Most studies were of fair methodological quality. Limitations included that samples were skewed towards US army veterans. Little research exists concerning those that have ceased military service.

CONCLUSIONS

Veteran help-seeking is likely enabled by poor mental health symptomology and comorbidity, which suggests veterans reach a crisis point before they seek help. Further research on alcohol misuse and attitude formation is required. The field would also benefit from alternative study designs including qualitative studies with non-US participants.

Veteran help-seeking behaviour for mental health issues: a systematic review

INTRODUCTION

Serving military personnel and veterans have been identified to have a high prevalence of mental health disorders. Despite this, only a significantly small number seek mental healthcare. With the UK beginning to invest further support to the armed forces community, identification of barriers and facilitators of help-seeking behaviour is needed.

METHODS

Corresponding literature search was conducted in PsycINFO, PsycArticles, Medline, Web of Science and EBSCO. Articles which discussed barriers and facilitators of seeking help for mental health concerns in the veteran population were included. Those which discussed serving personnel or physical problems were not included within this review. A total of 26 papers were analysed.

RESULTS

A number of barriers and facilitators of help-seeking for a mental health issue within the veteran population were identified. Barriers included stigma, military culture of stoicism and self-reliance, as well as deployment characteristics of combat exposure and different warzone deployments. Health service difficulties such as access and lack of understanding by civilian staff were also identified. Facilitators to help combat these barriers included a campaign to dispel the stigma, including involvement of veterans and training of military personnel, as well as more accessibility and understanding from healthcare staff.

CONCLUSIONS

While some barriers and facilitators have been identified, much of this research has been conducted within the USA and on male veterans and lacks longitudinal evidence. Further research is needed within the context of other nations and female veterans and to further indicate the facilitators of help-seeking among veterans.

Medical illness burden is associated with greater PTSD service utilization in a nationally representative survey

OBJECTIVE

Posttraumatic stress disorder (PTSD) is associated with higher rates of many medical conditions and higher use of medical health care services. Growing evidence suggests that comorbid medical illness in PTSD may in turn be associated with greater use of mental health treatment. However, no study to date has examined the impact of cumulative medical illness burden on PTSD service utilization.

METHOD

Data come from the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions. PTSD was assessed via structured interview, and cumulative medical illness burden was assessed via a survey of medical conditions. Logistic regression modeling examined associations between cumulative medical illness burden and odds of receiving PTSD treatment.

RESULTS

In the final sample of 1599 individuals with current PTSD, controlling for demographic characteristics, insurance status, psychiatric comorbidity and PTSD symptom count, higher levels of past-year medical illness were associated with increased odds of receiving past-year treatment for PTSD (odds ratio = 1.10, 95% confidence interval = 1.01-1.20, P = .029).

CONCLUSIONS

Greater levels of medical illness are associated with increased odds of PTSD service utilization. Greater medical comorbidity may increase the need for PTSD care by exacerbating symptoms or increase contact with medical services promoting PTSD detection and treatment.

Early mental health treatment-seeking among U.S. National Guard soldiers deployed to Iraq

The authors examined rates of and factors associated with postdeployment treatment-seeking in a panel of 424 National Guard soldiers who spent 16 months in Iraq. Soldiers completed a self-report, mailed survey 3- to 6-months after returning home. Approximately one third of respondents reported postdeployment mental health treatment. Those who screened positive for mental health problems were more likely to indicate that they had received treatment compared to those who screened negative, but over one half of those who screened positive were not engaged with mental health treatment. Variables related to reported treatment receipt included positive attitudes about mental health therapies, having been injured in-theater, illness-based need, and having received mental health treatment while in-theater. Implications and future research directions are discussed.

Equity in Veterans Affairs disability claims adjudication in a national sample of veterans

OBJECTIVES

To address potential equity concerns about the U.S. Department of Veterans Affairs' (VA) process for adjudicating military service-related disability claims.

METHODS

Participants were a nationally representative sample of 20,048 veterans completing the 2001 National Survey of Veterans. Sociodemographic, access, and illness correlates of both the award and rate of general disability benefits awarded by the VA were examined using an established theoretical framework.

RESULTS

Sociodemographic, access, and illness variables were associated with both the award ("yes/no") and rate of benefits (0-100%) awarded, with combat exposure, unemployment, and physical impairment accounting for the strongest model effects.

CONCLUSIONS

Veterans' needs were not overshadowed by factors related to demographic background or access (e.g., race, gender, insurance), reducing concerns about disparities in general VA disability disbursements. These data are timely as disability claims/payments will likely increase dramatically in the near future because of current conflicts in the Middle East.

Post-traumatic stress disorder and health problems among medically ill Canadian peacekeeping veterans

OBJECTIVE

The aim of the present study was to examine the relationship between post-traumatic stress disorder (PTSD) symptom severity and four significant health conditions (gastrointestinal disorders, musculoskeletal problems, headaches, and cardiovascular problems).

METHOD

Participants included 707 Canadian peacekeeping veterans with service-related disabilities, from a random, national Canadian survey, who had been deployed overseas.

RESULTS

PTSD severity was significantly related to gastrointestinal disorders, musculoskeletal problems, and headaches, but not to cardiovascular problems. Controlling for demographic factors did not affect PTSD's relationships with the three significant health conditions.

CONCLUSIONS

The present study supports previous work in finding consistent relations between PTSD severity and specific types of medical problems.

Outpatient medical and mental healthcare utilization models among military veterans: results from the 2001 National Survey of Veterans

Using Andersen's (1995) [Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? Journal of Health and Social Behavior 1995;36:1-10] behavioral model of healthcare use as our theoretical framework, we examined predisposing (i.e., sociodemographic), enabling (i.e., access resources), and need (i.e., illness) models of outpatient medical and mental healthcare utilization among a national sample of US veterans. Participants were 20,048 nationally representative participants completing the 2001 National Survey of Veterans. Outcomes were healthcare use variables for the past year, including the number of Veterans Affairs (VA) and non-VA outpatient healthcare visits, and whether VA and non-VA mental health treatment was used. Univariate results demonstrated that numerous predisposing, enabling and need variables predicted both VA and non-VA healthcare use intensity and mental healthcare use. In multivariate analyses, predisposing, enabling and need variables demonstrated significant associations with both types of healthcare use, but accounted for more variance in mental healthcare use. Need variables provided an additive effect over predisposing and enabling variables in accounting for medical and mental healthcare use, and accounted for some of the strongest effects. The results demonstrate that need remains an important factor that drives healthcare use among veterans and does not seem to be overshadowed by socioeconomic factors that may create unfair disparities in treatment access.

Veterans' disclosure of trauma to healthcare providers

OBJECTIVE

The purpose of this study is to gain a better understanding of patients' trauma disclosure to health professionals.

METHOD

A convenience sample of 173 veterans in outpatient treatment for posttraumatic stress disorder (PTSD) in the Veterans Health Administration completed surveys querying trauma history, reasons for trauma disclosure and perceived provider responses.

RESULTS

For half of the participants, a healthcare provider was the first person to whom they disclosed. Reasons were primarily external, such as pressure from others. Although 72% were glad to disclose, 45% perceived at least one negative provider response.

CONCLUSION

Patients disclose to a wide range of provider types and perceive varied responses. Providers' awareness of the need to be sensitive to trauma disclosure could facilitate treatment for PTSD.

Predictors of general medical and psychological treatment use among a national sample of peacekeeping veterans with health problems

We investigated general medical and psychological treatment use predictors among peacekeeping veterans with health problems, aiming to find those characteristics most associated with treatment use intensity (i.e., visit counts). One thousand one hundred and thirty-two male Canadian Forces peacekeeping veterans registered with Veterans Affairs for health problems were randomly recruited for a prospective national survey. Regression analyses for treatment use intensity controlled for age, total time deployed and health problems (covariates), and examined the incremental contribution of depression and post-traumatic stress disorder (PTSD) severity on health service use intensity. Results revealed that after controlling for covariates, the depression and PTSD model was associated with increased medical and psychological treatment use intensity. Medical use intensity was significantly predicted by married status, greater depression and health problems; psychological treatment use intensity was predicted by younger age, greater PTSD severity and health problems. This study highlights the importance of an integrated primary care-mental health service delivery model for veterans.

Symptom severity and lifetime and prospective health service use among military veterans evaluated for PTSD

We used structural equation modeling with 174 treatment-seeking military trauma survivors evaluated for posttraumatic stress disorder (PTSD) at a VA Medical Center PTSD clinic to examine relationships among lifetime mental health service use, PTSD symptom severity and medical problems (from self-report), as well as prospective (1-year) mental health and medical care use visit counts extracted from medical records. We discovered an adequate statistical fit to a hypothesized model of previous and prospective health service use, and current PTSD severity and health-related problems. Previous inpatient mental health treatment was significantly related to PTSD severity and prospective outpatient mental health use. However, PTSD severity was unrelated to prospective use of mental health or medical services. Health problems were related to prospective medical service use. Clinical and administrative implications in predicting health care use among trauma survivors are discussed.

Physical and sexual violence and health care utilization in HIV-infected persons with alcohol problems

We examined interpersonal violence and its association with health care utilization and substance use severity among a cohort of 349 HIV-infected men and women with histories of alcohol problems assessed biannually up to 36 months. Data included demographics, lifetime interpersonal violence histories, age at first violence exposure, recent violence (prior six months), substance use severity and health care utilization (ambulatory visits, Emergency Department (ED) visits, hospitalizations) and adherence to HIV medication. Kaplan-Meier survival curves estimated the proportion of subjects experiencing recent violence. Generalized estimating equation regression models evaluated the relationship between recent violence, utilization and substance use severity over time, controlling for demographics, CD4 counts and depressive symptoms. Subject characteristics included: 79% male; mean age 41 years; 44% black, 33% white and 23% other. Eighty percent of subjects reported lifetime interpersonal violence: 40% physical violence alone, and 40% sexual violence with or without physical violence. First violence occurred prior to age 13 in 46%. Twenty-four (41%) of subjects reported recent violence by 24 and 36 months, respectively. In multivariate analyses, recent violence was associated with more ambulatory visits, ED visits and hospitalizations and worse substance use severity, but not medication adherence. Due to the high incidence and associated increased health care services utilization, violence prevention interventions should be considered for HIV-infected patients with a history of alcohol problems.

Predictors of veterans' participation in cognitive-behavioral group treatment for PTSD

Increasingly effective treatments for posttraumatic stress disorder (PTSD) have led to dramatic improvements in the lives of many trauma survivors; however, a significant subgroup of individuals with PTSD avoids mental health treatment. Little is known about the features distinguishing those who participate in treatment from those who do not. We analyzed archival clinical data from 197 male veterans who were evaluated in a Veterans Affairs Medical Center PTSD clinic. We found greater PTSD severity associated with initial enrollment and continued participation in a PTSD group treatment program, and we noted few differences on other background and symptom measures. These preliminary findings suggest possible directions for future research in this area, which may have implications for enhancing service delivery to individuals with PTSD.

Postwar experiences and treatment-seeking behavior in a community counselling setting

Previous research investigating the impact of postwar experiences on Vietnam veterans has focused on veteran morbidity. This emphasis has meant that the impact of these factors on treatment-seeking behavior has received little empirical attention. This study examined the association between postwar factors and treatment-seeking behavior in a sample of 692 Australian Vietnam veterans. Logistic regression analyses were used to compute the odds ratios associated with postwar experiences and self-referral to a community-based counselling service. Results suggest that veterans who reported experiencing negative feelings toward others when they first arrived home were more likely to seek treatment. Other factors, such as a veteran's perception of societal attitudes and the reception they received, were not associated with treatment-seeking behavior.