Mental Health Stigma in Department of Defense Policies: Analysis, Recommendations, and Outcomes.

INTRODUCTION: Mental health stigma is one of the most frequently reported barriers to mental health help-seeking in the military. Previous research has identified that stigma-increasing language in the United States military policies was a potential deterrent to treatment-seeking. In response to a 2016 Government Accountability Office report recommendation, the current study conducted a comprehensive review of Department of Defense and military service-specific policies to identify stigmatizing language provisions and recommend appropriate language changes. METHODS: This review of policies comprised three sequential phases. First, a key-term search strategy was conducted on mental health (Phase 1) and substance misuse policies (Phase 2) to identify language that may contribute to stigma. Recommended language changes were identified, and the results of each phase were briefed to service-level Directors of Psychological Health. Approximately three years after initial identification, all mental health policies from Phase 1 for which language change recommendations had been made were examined to determine whether or not recommended changes had been incorporated (Phase 3). RESULTS: Out of 285 mental health and substance misuse policies, 191 (67%) contained potentially stigmatizing language. Subsequent review of implementation showed that partial or full recommended language changes had been made in 58.9% of 129 mental health-related policies that had been re-issued. CONCLUSIONS: This collaborative effort to identify and modify potentially stigmatizing language contributed to a substantial reduction in problematic policies across the military services. Future efforts should focus on reviewing new and re-issued policies to ensure that stigma-increasing language is not present as part of routine issuance. These efforts are part of ongoing work to address the association that language and terminology have on stigma and barriers to care.

PTSD treatment for soldiers after combat deployment: low utilization of mental health care and reasons for dropout.

OBJECTIVE: Limited data exist on the adequacy of treatment for posttraumatic stress disorder (PTSD) after combat deployment. This study assessed the percentage of soldiers in need of PTSD treatment, the percentage receiving minimally adequate care, and reasons for dropping out of care. METHODS: Data came from two sources: a population-based cohort of 45,462 soldiers who completed the Post-Deployment Health Assessment and a cross-sectional survey of 2,420 infantry soldiers after returning from Afghanistan (75% response rate). RESULTS: Of 4,674 cohort soldiers referred to mental health care at a military treatment facility, 75% followed up with this referral. However, of 2,230 soldiers who received a PTSD diagnosis within 90 days of return from Afghanistan, 22% had only one mental health care visit and 41% received minimally adequate care (eight or more encounters in 12 months). Of 229 surveyed soldiers who screened positive for PTSD (PTSD Checklist score ≥50), 48% reported receiving mental health treatment in the prior six months at any health care facility. Of those receiving treatment, the median number of visits in six months was four; 22% had only one visit, 52% received minimally adequate care (four or more visits in six months), and 24% dropped out of care. Reported reasons for dropout included soldiers feeling they could handle problems on their own, work interference, insufficient time with the mental health professional, stigma, treatment ineffectiveness, confidentiality concerns, or discomfort with how the professional interacted. CONCLUSIONS: Treatment reach for PTSD after deployment remains low to moderate, with a high percentage of soldiers not accessing care or not receiving adequate treatment. This study represents a call to action to validate interventions to improve treatment engagement and retention.

Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war.

CONTEXT: To promote early identification of mental health problems among combat veterans, the Department of Defense initiated population-wide screening at 2 time points, immediately on return from deployment and 3 to 6 months later. A previous article focusing only on the initial screening is likely to have underestimated the mental health burden. OBJECTIVE: To measure the mental health needs among soldiers returning from Iraq and the association of screening with mental health care utilization. DESIGN, SETTING, AND PARTICIPANTS: Population-based, longitudinal descriptive study of the initial large cohort of 88 235 US soldiers returning from Iraq who completed both a Post-Deployment Health Assessment (PDHA) and a Post-Deployment Health Re-Assessment (PDHRA) with a median of 6 months between the 2 assessments. MAIN OUTCOME MEASURES: Screening positive for posttraumatic stress disorder (PTSD), major depression, alcohol misuse, or other mental health problems; referral and use of mental health services. RESULTS: Soldiers reported more mental health concerns and were referred at significantly higher rates from the PDHRA than from the PDHA. Based on the combined screening, clinicians identified 20.3% of active and 42.4% of reserve component soldiers as requiring mental health treatment. Concerns about interpersonal conflict increased 4-fold. Soldiers frequently reported alcohol concerns, yet very few were referred to alcohol treatment. Most soldiers who used mental health services had not been referred, even though the majority accessed care within 30 days following the screening. Although soldiers were much more likely to report PTSD symptoms on the PDHRA than on the PDHA, 49% to 59% of those who had PTSD symptoms identified on the PDHA improved by the time they took the PDHRA. There was no direct relationship of referral or treatment with symptom improvement. CONCLUSIONS: Rescreening soldiers several months after their return from Iraq identified a large cohort missed on initial screening. The large clinical burden recently reported among veterans presenting to Veterans Affairs facilities seems to exist within months of returning home, highlighting the need to enhance military mental health care during this period. Increased relationship problems underscore shortcomings in services for family members. Reserve component soldiers who had returned to civilian status were referred at higher rates on the PDHRA, which could reflect their concerns about their ongoing health coverage. Lack of confidentiality may deter soldiers with alcohol problems from accessing treatment. In the context of an overburdened system of care, the effectiveness of population mental health screening was difficult to ascertain.

Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan.

CONTEXT: The US military has conducted population-level screening for mental health problems among all service members returning from deployment to Afghanistan, Iraq, and other locations. To date, no systematic analysis of this program has been conducted, and studies have not assessed the impact of these deployments on mental health care utilization after deployment. OBJECTIVES: To determine the relationship between combat deployment and mental health care use during the first year after return and to assess the lessons learned from the postdeployment mental health screening effort, particularly the correlation between the screening results, actual use of mental health services, and attrition from military service. DESIGN, SETTING, AND PARTICIPANTS: Population-based descriptive study of all Army soldiers and Marines who completed the routine postdeployment health assessment between May 1, 2003, and April 30, 2004, on return from deployment to Operation Enduring Freedom in Afghanistan (n = 16,318), Operation Iraqi Freedom (n = 222,620), and other locations (n = 64,967). Health care utilization and occupational outcomes were measured for 1 year after deployment or until leaving the service if this occurred sooner. MAIN OUTCOME MEASURES: Screening positive for posttraumatic stress disorder, major depression, or other mental health problems; referral for a mental health reason; use of mental health care services after returning from deployment; and attrition from military service. RESULTS: The prevalence of reporting a mental health problem was 19.1% among service members returning from Iraq compared with 11.3% after returning from Afghanistan and 8.5% after returning from other locations (P<.001). Mental health problems reported on the postdeployment assessment were significantly associated with combat experiences, mental health care referral and utilization, and attrition from military service. Thirty-five percent of Iraq war veterans accessed mental health services in the year after returning home; 12% per year were diagnosed with a mental health problem. More than 50% of those referred for a mental health reason were documented to receive follow-up care although less than 10% of all service members who received mental health treatment were referred through the screening program. CONCLUSIONS: Combat duty in Iraq was associated with high utilization of mental health services and attrition from military service after deployment. The deployment mental health screening program provided another indicator of the mental health impact of deployment on a population level but had limited utility in predicting the level of mental health services that were needed after deployment. The high rate of using mental health services among Operation Iraqi Freedom veterans after deployment highlights challenges in ensuring that there are adequate resources to meet the mental health needs of returning veterans.