The mental and physical sequelae of war threaten the fabric and quality of life for record numbers of Veterans and their families. Since the launch of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) in 2001 and 2003, respectively, more than 1.6 million U.S. Veterans have served, with one or multiple deployments. OEF/OIF Veterans have a high rate of mental health disorders (11.3% to 42.7%), notably posttraumatic stress disorder (PTSD), major depression, generalized anxiety, and substance misuse (Hoge et al., 2004). Equally common are medical and physical health issues, including diagnosis of pain, traumatic brain injury (TBI), limb loss and amputations, head injuries, and reduced functional status (Reiber et al., 2010). Relative to their need for help, low numbers of OEF/OIF Veterans seek and use available health care services (Hoge et al., 2004; Seal et al. 2010). Veterans reported that they are not concerned about access to care, but that their pride and inability to ask for help or admit to having a problem are barriers to seeking needed and available care (Stecker, Fortney, Hamilton, & Ajzen, 2007). Having access to available treatment is not enough to ensure that Veterans will engage in health care–seeking behaviors, such as seeking treatment and using health care resources.
The Veterans Affairs Healthcare System (VA) is an equal-access health care system with initiatives to eliminate health care disparities and improve Veterans’ health care outcomes. OEF/OIF Veterans qualify for free health care for 5 years post deployment for service-related health issues. Findings from other studies also highlight the discrepancy between Veterans’ increased health care needs and their relatively low use of health care services. Among 6,201 OEF/OIF combat Veterans, of those who screened positive for major depression, generalized anxiety, or PTSD, only 23% to 40% sought mental health care (Hoge et al., 2004). Unmet health care needs may have negative health consequences, including new or escalating medical and mental health disorders, alcohol and substance misuse, self-care deficits, and suboptimal psychosocial functioning. We begin with a discussion of the role of masculinity in health care–seeking behaviors and then summarize current literature on OEF/OIF Veterans’ health care needs, including barriers and facilitators to seeking health care. The aim is to provide information to psychiatric mental health nurses and other health care providers to support effective interventions that help Veterans obtain needed care.
Database searches were conducted in EBSCO, PubMed, PsycINFO, and SocioIndex. Reference lists in identified articles were manually searched for additional relevant articles. Empirical studies conducted from 2001 to 2013 that reported on mental and medical health prevalence, health-seeking, health care resource utilization, and help-seeking barriers and facilitators of OEF/OIF Veterans or active duty personnel were reviewed. The key words/phrases and medical subject heading terms used were: OEF/OIF Veterans AND help-seeking, OEF/OIF Veterans AND health resource utilization, masculinity AND help-seeking, military culture AND help-seeking, and help-seeking barriers OR facilitators.
Masculinity and Health Care-Seeking Behavior
Compared to female Veterans, male OEF/OIF Veterans report fewer medical health issues, are less likely to use outpatient health care services, are less interested in receiving health care, and have longer delays in seeking mental health care post deployment (Maguen et al., 2012). In the United States, a White man who is heterosexual, strong, stoic, and physically aggressive represents traditional masculinity. The need to conform to the characteristics of being strong and stoic reinforces health-compromising behaviors that are socioculturally defined and accepted (Courtenay, 2000). Endorsing traditional masculinity impacts men’s health attitudes, values, beliefs, help-seeking behaviors, and health. Similarly, Green, Emslie, O’Neill, Hunt, and Walker (2010) found that masculine values of strength, aggression, stoicism, and endurance informed the construction of soldier identity among United Kingdom ex-servicemen. The authors reported that emotional expression may be contrary to these values, and participants may lack the language needed to express emotional distress leading to delays in seeking care. They suggested that traditional masculinity values are part of a soldier’s identity, and that those who adhere to traditional masculinity values, including stoicism, consider the expression of emotional distress inappropriate. Lacking language to express distress may lead to delays in identifying mental health problems and seeking mental health care. Duck (2009) reported that Black men in the United States engaged in risky health behaviors and avoided seeking health care because seeking health care was seen as weakness and unmanly.
Thus, traditional ideas of masculinity may be related to men having poorer health, with higher morbidity and mortality, lower life expectancy, poorer health promotion, and greater likelihood of high-risk behaviors (e.g., smoking, alcohol/drug use) compared to women. The Centers for Disease Control and Prevention (CDC, 2011) reported that life expectancy for men in the United States is 5 years lower than for women, and men die disproportionately from coronary heart disease, stroke, and other preventable diseases. It is probable that military culture magnifies traditional ideas of masculinity and thus amplifies the risk for poorer health care among Veterans.
Mental Health Issues
The prevalence rates for mental health disorders differ across military service branches, places of deployment, and types of disorders. Compared to OEF Veterans, OIF Veterans reported more mental health issues and were exposed to more combat experiences. Hoge et al. (2004) found that 71% (n = 1,709) of OEF soldiers and Marines reported engaging in firefight compared to 31% (n = 1,962) of a similar group deployed to Afghanistan.
PTSD is the most prevalent mental health disorder reported by OIF/OEF Veterans (Hoge et al., 2004). The prevalence rates of mental health disorders and PTSD among Veterans have increased since the onset of the OEF/OIF wars (Seal et al., 2009). Seal et al. (2009) reported that the percentage of Veterans with a mental health disorder increased from 6.4% in 2002 to 36.9% in 2008, PTSD increased from 0.2% to 21.8%, and depression from 2.3% to 17.4% during that time. Those on active duty, of a young age (18 to 24), male, of a lower rank, and serving in the Army or Marines had a higher risk for PTSD compared to those who were older (age ≥40), female, of a higher rank, and serving in other military branches. PTSD has a high comorbidity rate with major depression, generalized anxiety, and alcohol and substance use disorders (Hoge et al., 2004). The risk for PTSD increased with longer lasting or repeated deployment, traumatic combat experiences (e.g., handling dead bodies, witnessing landmine strikes, seeing another wounded or killed), injury during combat, and branch of service, particularly being Marine or Army (Hoge et al., 2004). Among OEF/OIF Veterans, those with higher levels of PTSD symptom severity are at greater risk for sleep and daytime dysfunction. Those with higher levels of worry and fear of loss of vigilance are more likely to experience sleep difficulties, whereas those with higher levels of cognitive distraction and greater military unit member support are less likely to experience sleep difficulties (Pietrzak, Morgan, & Southwick, 2010).
High prevalence of substance abuse among OEF/OIF Veterans has been reported (Seal et al., 2011). Similar to PTSD, increased risks for alcohol and drug use disorders were related to deployment, traumatic combat experiences, branch of military service, and having a mental health disorder. Veterans who were males, ages 18 to 24, of junior rank, Army or Marine, exposed to combat, deployed to Iraq, and had PTSD and/or depression were more likely to report alcohol and substance abuse (Seal et al., 2011).
Suicide rates are relatively high among OEF/OIF Veterans. Bagalman (2011) reported a rate of 38 completed suicides per 100,000 OEF/OIF Veterans receiving care at the VA. In comparison, in the general population, the reported suicide rates for men ages 15 to 24 and 25 to 44 in 2010 were 16.9 and 23.6 per 100,000, respectively (CDC, 2011). PTSD, depression, and increased psychosocial difficulty increased the risk for suicidal ideation, whereas social support and a sense of purpose lessened the risk for suicidal ideation. In a sample of 272 OEF/OIF Veterans, Pietrzak et al. (2010) reported that those with suicidal ideation were more likely to experience PTSD, depression, alcohol abuse, and to score higher on measures of stigma, psychosocial difficulties, and barriers to care. They equally tended to score lower on measures of resilience and social support compared to those without suicidal ideation. Having more social support, a sense of purpose, and a sense of control decreased the likelihood of having suicidal ideation.
OEF/OIF Veterans with a positive PTSD screen and with two or more comorbidities were 5.7 times as likely to experience suicidal ideation as those with PTSD without comorbidities. Those with major depressive disorder, alcohol abuse, and older age were at increased risk for suicidal ideation.
OEF/OIF Veterans with mental health symptoms are unlikely to obtain adequate treatment such as completing nine sessions of psychotherapy treatment within 15 weeks. Among Veterans newly diagnosed with PTSD (N = 49,425), only 9.5% completed an adequate treatment course of nine or more follow-up mental health visits within 15 weeks (Seal et al., 2010).
Medical Health Issues
It is doubly important for those working in mental health to understand the medical health issues of OEF/OIF Veterans. The first reason is because medical disorders are often associated with mental health disorders and second, because Veterans may need mental health interventions to seek and receive the care they need for their medical conditions. TBI is the signature injury of the Afghanistan and Iraq wars. Health outcomes of memory loss, headaches, dizziness, sleep disturbances, concussions, intracranial hemorrhage, and head injuries were reported (Morissette et al., 2011). TBI is highly associated with mental health disorders, especially PTSD and depression. Pietrzak, Johnson, Goldstein, Malley, and Southwick (2009) found that 18.8% (n = 277) of OEF/OIF Veterans screened positive for mild TBI and 32% of those with PTSD reported injuries with loss of consciousness. Veterans with mild TBI were younger, had unmet medical and psychological needs, high perceived barriers to mental health care, and work-related difficulties. Of OEF/OIF Veterans who screened positive for TBI, a majority reported combat exposure, PTSD, depression, having at least one post concussive symptom (e.g., headache, balance problem/dizziness, memory problem) (Morissette et al., 2011), and more missed workdays.
Combat-related physical injury, PTSD, and substance abuse are all more likely for those who experience headaches (Afari et al., 2009). Of 308 OEF/OIF Veterans, 40% reported current headache, 10% reported migraines, 12% reported tension headaches, and 6% reported having both migraines and tension headaches. Of those reporting headaches, many also reported experiencing combat-related physical injury (26.2%) and depression (59.8%). Veterans with combat-related physical injuries or PTSD were more likely to have physician-diagnosed migraine or tension headache or both types of headaches, or self-reported headaches, than those without combat injury or PTSD. In addition, those with substance use disorders were more likely to have self-reported headaches. Compared to non-Veteran peers, these Veterans are more likely to have numerous medical health issues including traumatic limb loss, surgical amputations, head traumas, hearing loss, spine disorders, hypertension, asthma, and gastroesophageal reflux (Reiber et al., 2010).
Pain and pain-related conditions are the medical health issues reported most by OEF/OIF Veterans. In a VA study of 283 OEF/OIF Veterans, Reiber et al. (2010) reported that 42% experienced back pain, 76% phantom pain, and 63% residual-limb pain. Chronic pain limits physical functioning independently and is associated with PTSD, depression, and alcohol use disorders.
Male Veterans ages 25 to 64 were more likely to be current smokers than non-Veterans. Cigarette smoking and tobacco use among OEF/OIF Veterans is even higher, especially among Veterans with PTSD and those of younger ages (Kirby et al., 2008). Veterans with more severe PTSD symptoms, particularly emotional numbing, are likely to be heavy smokers (≥20 cigarettes per day). To cope with being deployed, individuals in the military may begin smoking and then they may continue to use tobacco products as a coping strategy post deployment (Kirby et al., 2008). In the study by Kirby et al. (2008), among 90 Veterans with PTSD, 59% reported a lifetime history of smoking and 50% smoked ≥20 cigarettes per day. Many reported beginning to smoke after experiencing combat-related trauma.
Seeking treatment may depend on the individual’s perception, values, and beliefs about health issues and their need for care (Table 1). In a VA study, OEF/OIF Veterans’ decisions to seek care were based on their earned benefit for military service, injuries, and need for help (Randall, 2012). Veterans who recognized that they had a health problem and were interested in receiving help were more likely to take the initiative to seek health care and to follow through with the resulting plan of care. However, an individual may perceive a need for health care without intending to receive care. Among 577 combat Veterans who screened positive for PTSD, depression, or generalized anxiety disorder, more than three quarters recognized that they currently had a mental health problem but only 40% indicated an interest in receiving help. Those who were interested in receiving help were more likely to have had previous mental health care. Veterans with a negative attitude toward mental health treatment or a rank of E7 and above were less interested in receiving help (Brown, Creel, Engel, Harrell, & Hoge, 2011). Sayer et al. (2009) reported that Veterans were more likely to receive treatment for PTSD if they recognized that they had the disorder, treatment service was available, and they held beliefs that favored receiving treatment. Health care system factors, including a web-based referral system, routine screening for symptoms, mental health referrals when indicated, and feeling a sense of trust in the provider, increased the likelihood that an individual would seek needed help. Having a social network to provide emotional support and information about health and available resources also made it more likely that Veterans would receive needed help.
Health-Seeking Facilitators and Barriers
Two studies from the United Kingdom and Canada are helpful in understanding the problems that Veterans may have in recognizing and seeking health care. In a U.K. study of regular and reserve personnel (n = 821), three quarters of those with depression, anxiety, or PTSD recognized that they had a problem, whereas only half of those with alcohol abuse recognized they had a problem. The participants sought help mostly from nonprofessional sources. Royal Air Force Veterans, female reservists, and those with a medical or mental health diagnosis were more likely to seek health care (Iversen et al., 2010). In a Canadian study of active military personnel (N = 8,441), Sareen, Belik, Stein, and Asmundson (2010) reported that a self-perceived need for mental health care, especially for panic disorder, was associated with female gender, marital status other than never being married, middle income, long-term restriction in activities, physical injury and disabilities, suicidal ideation, regular service status, mental disorder comorbidity, junior rank, age 35 to 44, and deployment-related factors of deployment exposure, being in combat, or witnessing atrocities.
Veterans who had a positive mental health screen or were diagnosed with a mental health disorder, especially PTSD, were more likely to seek mental health treatment after their deployment (Hoge et al., 2004; Kehle et al., 2010). Kehle et al. (2010) found that of 424 National Guard soldiers who served in Iraq, 34.7% reported receiving mental health services post deployment. Those who reported being injured in Iraq, had received treatment before their deployment, had high levels of PTSD and depressive symptoms, had higher levels of post-deployment stressors, poorer health, and a positive attitude toward mental health treatment were more likely to receive post-deployment psychotherapy or medication. Psychiatric medication use was related to interest in receiving mental health care, poor social support, and having a mental health problem. OEF/OIF Veterans who were female, older, active duty status, of lower rank, and had a mental health diagnosis with comorbidities were more likely to receive non-mental health care (Cohen et al., 2009).
Multiple barriers to seeking health care have been identified in the general population, including race, lack of health insurance coverage, poverty, low social economic status, lack of health information, and lack of physician trust (Thompson, Talley, Caito, & Kreuter, 2009). Somnath, Freeman, Toure, Tippens, and Weeks (2007) found similar barriers in the VA: lack of knowledge regarding health care interventions, lack of trust in the provider’s clinical judgment and in the usefulness of the treatment, and inadequate social support and resources. Unfortunately, a lack of trust in the providers and the quality of care is sometimes well founded. The authors reported that minority Veterans, particularly African Americans, were less trusting of the benefits of medical interventions than White Veterans and that clinician treatment decisions varied by Veterans’ race. Some VA facilities serving minority Veterans had fewer available services and provided a lower quality of care compared to those serving predominantly White Veterans.
OEF/OIF Veterans with negative attitudes and beliefs about mental health care were less likely to be interested in receiving help (Brown et al., 2011; Stecker et al., 2007). Among OEF/OIF Veterans (n = 44), half receiving treatment and half not receiving treatment, Sayer et al. (2009) identified personal, health care system, and social barriers to initiating mental health treatment. Both groups reported similar barriers to seeking care, but they were more intense for those who were not receiving treatment. For those receiving treatment, although the barriers were less intense, they still resulted in delays for seeking treatment. Personal barriers were a desire to avoid discussion of traumatic experiences and holding values or having priorities that conflicted with seeking treatment. These barriers include pride in self-reliance; treatment discouraging beliefs, such as that providers will not believe the traumatic event(s) occurred, that treatment is not effective, treatment is for the weak or the crazy, or is only needed in extreme cases; and knowledge barriers, such as lack of knowledge about PTSD and services available. Health care system barriers included difficulties accessing care, such as the time needed, treatment cost, problems with transportation and long distances to access care, and VA enrollment processes. Social barriers were negative homecoming experiences, lack of social support, and society’s discouragement of seeking help. Other researchers have reported similar findings (Table 1). OEF/OIF Veterans reported embarrassment, pride, issues with self-esteem, not wanting to be seen as weak or a free-loader, and shame in asking for help (Randall, 2012).
Social stigmatization occurs when an individual is excluded or labeled as “other.” The subtexts of stigma and labeling are stereotyping and discrimination. Stereotypes are socially constructed undesirable characteristics that may foster rejection and limit the stigmatized individual’s participation in the dominant group. Anticipation of experiencing stigma was a major barrier to seeking mental health care among OEF/OIF Veterans (Hoge et al., 2004; Stecker et al., 2007). Kim, Thomas, Wilk, Castro, and Hoge (2010) compared two groups with mental health problems, former active duty soldiers and former National Guard soldiers, at 3 and 12 months post deployment. They found that the former active duty soldiers had stronger expectations than the National Guard soldiers that they would experience stigmatization for using mental health services. The health consequences of stigma for seeking mental health care included help-seeking delays or not seeking needed health care (Hoge et al., 2004), discontinuing mental health treatment (Seal et al., 2010), and low use of health care resources (Stecker et al., 2007).
The articles reviewed provide knowledge that can be applied to practice; however, many gaps remain. There is a need for further research designed to increase knowledge of male Veterans’ psychosocial, cultural, and cognitive processes, including their understanding of masculinity, related to their decisions to seek help and use health care services. Studies evaluating interventions designed to enhance access to care are also needed. Equally important are studies focusing on military culture and its impact on Veterans’ help-seeking behaviors. Given the high rate of suicide among Veterans, the understanding that a lack of language to express distress is related to suicide deserves further evaluation in the near future, with consideration of effective interventions to develop such language.
Implications for Practice
Veterans of the OIF/OEF wars are at high risk for mental and medical illnesses and for not receiving needed care or completing a needed course of care. They frequently experience comorbid illnesses. The symptoms Veterans experience related to mental disorders (e.g., PTSD avoidance symptoms), their understanding of their symptoms and diagnoses and of the help available to them, their expectations of those who provide the help, and of the likely outcomes of treatment all affect the probability that they will seek needed help. The degree of identification with a traditional sense of masculinity, possibly reinforced by military ideals, may be a major factor in identifying a need for health care and in obtaining needed care. Other factors in seeking help, particularly related to suicidal ideation, include having the language to express distress. It is noteworthy that those of higher rank who need health care may be less likely than those of lower rank to seek needed help. Although we did not find any literature to confirm this, we suspect that this trend is linked to a greater degree of identification with traditional masculinity/military ideals among those serving in higher ranks.
Interventions should focus on increasing facilitators to seeking health care and decreasing barriers at community, family, and individual levels (Table 2). Psychoeducation focusing on understanding symptoms, diagnoses, and the reasons for not seeking mental or medical health care should be provided at each level. As is common to many illnesses, and particularly to mental illnesses, there is a need to address the possible stigmatizing effect of having a diagnosis and receiving treatment. Education that includes information about how treatment can support achieving some of the masculinity/military ideals, such as being self-reliant, able to work, and provide for family, may help reduce the influence of related barriers, such as valuing stoicism, on health care seeking. Perhaps, most importantly, all Veterans should have access to excellent care. We have an obligation to ensure that all facilities provide such care, regardless of the predominant racial group they serve.
Interventions Focused on Modifying Barriers and Facilitators to Seeking Health Care
- Afari, N., Harder, L.H., Madra, N.J., Heppner, P.S., Moeller-Bertram, T., King, C. & Baker, D.G. (2009). PTSD, combat injury, and headache in veterans returning from Iraq/Afghanistan. Headache, 49, 1267–1276. doi:10.1111/j.1526-4610.2009.01517.x [CrossRef]
- Bagalman, E. (2011). Suicide, PTSD, and substance use among OEF/OIF Veterans using VA health care: Facts and figures. Retrieved from http://digital.library.unt.edu/ark:/67531/metadc96703/m1/1/high_res_d/R41921_2011Jul18.pdf
- Brown, M.C., Creel, A.H., Engel, C.C., Harrell, R.K. & Hoge, C.W. (2011). Factors associated with interest in receiving help for mental health problems in combat veterans returning from deployment to Iraq. Journal of Nervous and Mental Disease, 199, 797–801. doi:10.1097/NMD.0b013e31822fc9bf [CrossRef]
- Centers for Disease Control and Prevention. (2011). CDC Health disparities and inequalities report—United States. Retrieved from http://www.cdc.gov/mmwr/pdf/other/su6001.pdf
- Cohen, B.E., Gima, K., Bertenthal, D., Kim, S., Marmar, C.R. & Seal, K.H. (2009). Mental health diagnoses and utilization of VA non-mental health medical services among returning Iraq and Afghanistan veterans. Journal of General Internal Medicine, 25, 18–24. doi:10.1007/s11606-009-1117-3 [CrossRef]
- Courtenay, W.H. (2000). Constructions of masculinity and their influence on men’s well being: A theory of gender and health. Social Science & Medicine, 50, 1385–1401. doi:10.1016/S0277-9536(99)00390-1 [CrossRef]
- Duck, W. (2009). Black male sexual politics: Avoidance of HIV/AIDS testing as a masculine health practice. Journal of African American Studies, 13, 283–306. doi:10.1007/s12111-009-9097-2 [CrossRef]
- Green, G., Emslie, C., O’Neill, D., Hunt, K. & Walker, S. (2010). Exploring the ambiguities of masculinity in accounts of emotional distress in the military among young ex-servicemen. Social Science & Medicine, 71, 1480–1488. doi:10.1016/j.socscimed.2010.07.015 [CrossRef]
- Hoge, C.W., Castro, C.C., 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, 13–22. doi:10.1056/NEJMoa040603 [CrossRef]
- Iversen, A.C., van Staden, L., Hughes, J.H., Browne, T., Greenberg, N., Hotopf, M. & Fear, N.T. (2010). Help-seeking and receipt of treatment among UK service personnel. British Journal of Psychiatry, 197, 149–155. doi:10.1192/bjp.bp.109.075762 [CrossRef]
- Kehle, S.M., Polusny, M.A., Murdoch, M., Erbes, C.R., Arbisi, P.A., Thuras, P. & Meis, L.A. (2010). Early mental health treatment-seeking among U.S. National Guard soldiers deployed to Iraq. Journal of Traumatic Stress, 23, 33–40. doi:10.1002/jts.20480 [CrossRef]
- 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, 582–588. doi:10.1176/appi.ps.61.6.582 [CrossRef]
- Kirby, A.C., Hertzberg, B.P., Collie, C.F., Yeatts, B., Dennis, M.F., McDonald, S.D. & Beckham, J.C. (2008). Smoking in help-seeking veterans with PTSD returning from Afghanistan and Iraq. Addictive Behavior, 33, 1448–1453. doi:10.1016/j.addbeh.2008.05.007 [CrossRef]
- Maguen, S., Cohen, B., Cohen, G., Madden, E., Bertenthal, D. & Seal, K. (2012). Gender differences in health service utilization among Iraq and Afghanistan veterans with posttraumatic stress disorder. Journal of Women’s Health, 21, 666–673. doi:10.1089/jwh.2011.3113 [CrossRef]
- Morissette, S.B., Woodward, M., Kimbrel, N.A., Meyer, E.C., Kruse, M.I., Dolan, S. & Gulliver, S.B. (2011). Deployment-related TBI, persistent postconcussive symptoms, PTSD, and depression in OEF/OIF veterans. Rehabilitation Psychology, 56, 340–350. doi:10.1037/a0025462 [CrossRef]
- Pietrzak, R.H., Goldstein, M.B., Malley, J.C., Rivers, A.J., Johnson, D.C. & Southwick, S.M. (2010). Risk and protective factors associated with suicidal ideation in veterans of Operations Enduring Freedom and Iraqi Freedom. Journal of Affective Disorders, 123, 102–107. doi:10.1016/j.jad.2009.08.001 [CrossRef]
- Pietrzak, R.H., Johnson, D.C., Goldstein, M.B., Malley, J.C. & Southwick, S.M. (2009). Posttraumatic stress disorder mediates the relationship between mild traumatic brain injury and health and psychosocial functioning in veterans of Operations Enduring Freedom and Iraqi Freedom. Journal of Nervous and Mental Disease, 197, 748–753. doi:10.1097/NMD.0b013e3181b97a75 [CrossRef]
- Pietrzak, R.H., Morgan, C.A. III. & Southwick, S.M. (2010). Sleep quality in treatment-seeking veterans of Operation Enduring Freedom and Iraqi Freedom: The role of cognitive coping strategies and unit cohesion. Journal of Psychosomatic Research, 69, 441–448. doi:10.1016/j.jpsychores.2010.07.002 [CrossRef]
- Randall, M.J. (2012). Gap analysis: Transition of health care from Department of Defense to Department of Veterans Affairs. Military Medicine, 177, 11–16. doi:10.7205/MILMED-D-11-00226 [CrossRef]
- Reiber, G.E., McFarland, L.V., Hubbard, S., Maynard, C., Blough, D.K., Gambel, J.M. & Smith, D.G. (2010). Service members and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: Survey methods, participants, and summary findings. Journal of Rehabilitation Research and Development, 47, 275–298. doi:10.1682/JRRD.2010.01.0009 [CrossRef]
- Sareen, J., Belik, S.L., Stein, M.B. & Asmundson, G.J. (2010). Correlates of perceived need for mental health care among active military personnel. Psychiatry Services, 61, 50–57. doi:10.1176/appi.ps.61.1.50 [CrossRef]
- Sayer, N.A., Friedemann-Sanchez, G., Spoont, M., Murdoch, M., Parker, L.E., Chiros, C. & Rosenheck, R. (2009). A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry, 72, 238–255. doi:10.1521/psyc.2009.72.3.238 [CrossRef]
- Seal, K.H., Cohen, G., Waldrop, A., Cohen, B.E., Maguen, S. & Ren, L. (2011). Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001–2010: Implications for screening, diagnosis and treatment. Drug and Alcohol Dependence, 116, 93–101. doi:10.1016/j.drugalcdep.2010.11.027 [CrossRef]
- Seal, K.H., Maguen, S., Cohen, B., Gima, K.S., Metzler, T.J., Ren, L. & Marmar, C.R. (2010). VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. Journal of Traumatic Stress, 23, 5–16. doi:10.1002/jts.20493 [CrossRef]
- Seal, K.H., Metzler, T.J., Gina, K.S., Bertenthal, D., Maguen, S. & Marmar, C.R. (2009). Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002–2008. American Journal of Public Health, 99, 1651–1658. doi:10.2105/AJPH.2008.150284 [CrossRef]
- Somnath, S., Freeman, M., Toure, J., Tippens, K.M. & Weeks, C. (2007). Racial and ethnic disparities in the VA healthcare system: A systematic review. Retrieved from http://www.hsrd.research.va.gov/publications/esp/RacialDisparities-2007.pdf
- Stecker, T., Fortney, J.C., Hamilton, F. & Ajzen, I. (2007). An assessment of beliefs about mental health care among veterans who served in Iraq. Psychiatric Services, 58, 1358–1361. doi:10.1176/appi.ps.58.10.1358 [CrossRef]
- Thompson, V.S., Talley, M., Caito, N. & Kreuter, M. (2009). African American men’s perceptions of factors influencing health-information seeking. American Journal of Men’s Health, 3, 6–15. doi:10.1177/1557988307304630 [CrossRef]
Health-Seeking Facilitators and Barriers
Age >25 years
Age <25 years
Rank E7 and above
|Positive attitude toward mental health and mental health treatment
Recognizing and accepting PTSD
Receiving treatment before deployment
|Negative attitude/beliefs about mental health and mental health treatment
Treatment is ineffective
Personal beliefs and perception of mental illness and mental health care
Loss of control or autonomy
|Self-perceived need for care
Recognizing a health problem
Interest in receiving help
Labeled as being “crazy”
Being treated differently by unit leaders and members
Perceived ability to deal with the issue
Help-seeking as a sign of weakness
|Positive mental health screen or diagnosis, especially PTSD
PTSD with comorbid mental health disorders
More severe PTSD and depressive symptoms
Earned benefit for military service
Access issues (clinic location, urban living)
Perception of losing military career
Time off from work
Lack of knowledge (PTSD care, available services, and perceived ineligibility for VA care)
PTSD diagnosis received from a nonmental health clinic and outreach clinics
Access (time, cost, transportation, distance, VA enrollment processes)
Combat and active duty status
OIF Veterans (Army or Marine)
Combat experiences (witnessing atrocities, number of deployments, long-term restriction in activities, suicidal ideation in the past year)
|Masculinity norms and values
Pride in self-reliance
Focus on job and family
Sociocultural milieu that discourages seeking help
Interventions Focused on Modifying Barriers and Facilitators to Seeking Health Care
|Assessment for Factors That Affect the Likelihood of Seeking or Following Through With Treatment
|Demographic factors that may influence health care–seeking behaviors
Veterans of younger age or higher rank may be less likely to seek care
Men may be less likely than women to seek care
|Adherence to traditional ideals of masculinity
Veterans valuing strength and stoicism and devaluing emotional expression may be less likely to seek care
|Attitudes and fears about illness
Veterans with a negative attitude or beliefs about mental illness and the effectiveness of treatment are less likely to seek care
Fear of experiencing stigma if diagnosed and treated
Fear of losing military career if diagnosed and treated
Trust or lack of trust in health care providers
Past treatment experiences
|Understanding of symptoms and illness
Veterans with a positive screen or diagnosis of an illness may be more likely to seek care
Veterans who recognize that they have an illness and have an understanding of treatment may be more likely to seek care
|Knowledge about their entitlement to care and the availability of care, access to care, and the enrollment process to access care
|Interventions to Modify Factors That Affect the Likelihood of Seeking or Following Through With Treatment
|Educate military leaders, families, and communities that Veterans who are younger, of higher rank, or male may need concerted support to seek health care
|Educate Veterans that acknowledging and seeking treatment for symptoms of mental and medical illness are signs of strength and that such treatment will help them establish self-control and enhance their ability to decide when to express their emotions
|Educate Veterans about mental illness, to provide them with a language and a foundation for expressing their experiences and understanding their symptoms and illnesses
|Educate community members and leaders, including members of the military, about mental illness, emphasizing the harmful effects of stigmatization and the benefits of effective treatment
|Establish therapeutic relationships that provide Veterans with the experience of trusting a health care provider
|In general, focus on current issues rather than on past traumatic experiences that may evoke avoidance symptoms
|If the Veteran chooses to talk about traumatic experiences, practitioners should consider how they will manage their response, both in the time with the Veteran and afterward. Practitioners must consider their own self-care.