Care managers' experiences in a collaborative care program for the treatment of bipolar disorder and PTSD in underserved communities.

OBJECTIVES: To understand care managers' experiences treating primary care patients with bipolar disorder and PTSD in a telepsychiatry collaborative care (TCC) program, as part of a large pragmatic trial. METHODS: We conducted individual qualitative interviews with 12 care managers to evaluate barriers and facilitators to implementation of a previously completed TCC intervention for patients with bipolar disorder and/or PTSD. We used directed and conventional content analysis and Consolidated Framework for Implementation Research (CFIR) constructs to organize care manager experiences. RESULTS: Participants described clinical and medication management support from telepsychiatrists and satisfaction with the TCC model as facilitators of success for patients with bipolar disorder and PTSD in underserved communities. Participants also described onboarding of primary care providers and clinic leadership as keys to successful team-care and credited satisfaction with providing Behavioral Activation as essential to sustained delivery of the psychotherapy component of TCC. CONCLUSIONS: Participants described high satisfaction with TCC for patients with bipolar disorder and PTSD. Challenges included lack of clinic leadership and PCP engagement. Early and ongoing promotion of integrated care and prioritizing telepsychiatry consultation with patients, behavioral health professionals and PCPs, may improve patient care, provide ongoing training and improve workforce satisfaction.

Engaging stakeholders for change: A learning community methodology for implementing evidence-based, trauma-focused care on college campuses.

OBJECTIVE: Advances in implementation science have encouraged novel methods for disseminating and implementing evidence-based treatments. Mental health services offered to trauma-exposed students on college campuses are characterized by unique contextual, developmental, and cultural factors that must be considered to effectively disseminate and implement trauma-focused, evidence-based treatments (TF-EBTs). Informed by novel implementation designs, this project utilized a strategic stakeholder engagement method of creating a learning community to identify and adapt a TF-EBT for use in university counseling centers (UCCs). METHOD: Project leads convened campus and community stakeholders included UCC clinicians, administrators, student life professionals, and students, to join researchers in a reciprocal collaboration to work toward dissemination and implementation. These stakeholders participated in a learning community that reviewed, selected, and adapted a TF-EBT and other tools for dissemination and implementation to UCCs and other campus professionals. RESULTS: There were a number of benefits and challenges of using the learning community as a method of dissemination and implementation. Benefits included context-specific knowledge sharing, clarification of the scope of trauma among college students, creation of helpful tools, emphasis on cultural competence in TF-EBTs, and facilitating connections between professionals. Challenges included balancing flexibility with progress toward project goals and recruitment and retention of stakeholders. CONCLUSIONS: Stakeholder engagement is an integral component of dissemination and implementation efforts. The learning community method allowed for stakeholders to take an active part in adapting a TF-EBT for UCCs and can be utilized in other settings to aid in adoption and utilization of evidence-based treatments. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Access and attitudinal barriers to engagement in integrated primary care mental health treatment for rural populations.

PURPOSE: Compared to urban areas, rural populations are less likely to engage in mental health care. Using data from the Study to Promote Innovation in Rural Integrated Telepsychiatry, we examined the effect of rurality on engagement in mental health treatment as well as the role of potential mediators. METHODS: Data were obtained from medical records and surveys. We defined rurality using the rural-urban commuting area codes. Baseline mediators included the Endorsed and Anticipated Stigma Inventory and the Assessment of Perceived Access to Care. Engagement outcomes included number of psychotherapy visits and self-reported medication use. We used path analysis to examine the relationship between rurality and engagement and the influence of mediating variables. FINDINGS: Rural participants were less likely to initiate psychotherapy (OR = 0.49; adjusted P = .036), although rurality was not associated with number of psychotherapy sessions or medication use. Rurality was associated with a small elevation in negative beliefs about mental health, but this potential mediator was not associated with engagement. Rurality was negatively associated with lower perceived need for treatment (OR = 0.67, adjusted P = .040), which was in turn positively associated with initiating psychotherapy (OR = 1.99, adjusted P = .001). CONCLUSIONS: Neither rurality itself nor the potential mediators had a large effect on engagement. Federally Qualified Health Centers offering colocated and/or integrated mental health care appear to be mostly mitigating rural-urban disparities in mental health engagement. Improving rates of psychotherapy initiation for rural patients should remain a policy goal.

Posttraumatic stress disorder collaborative care: A quality improvement study in veterans affairs primary care.

Introduction: Collaborative care improves depression and anxiety outcomes. In this naturalistic, observational case study, we adapted an evidence-based depression collaborative care protocol for the assessment and treatment of posttraumatic stress disorder (PTSD) and sought to demonstrate that the protocol could be implemented in Veterans Affairs (VA) primary care. Method: Based on feedback from a content expert panel, clinical stakeholders, and a pilot study conducted in a postdeployment clinic, the original depression collaborative care protocol was modified to include PTSD assessment and support for PTSD medication adherence, self-management, and engagement in evidence-based PTSD care. Results: The modified program was implemented from November 2012 to March 2017, and 239 patients with PTSD were referred. Nearly two thirds (n = 185) enrolled, and they participated in the program for an average of 4 to 5 months and completed calls approximately once per month. Among patients with more than one assessment of clinical outcomes, 53.4% (n = 94) reported clinically significant improvement in depression on the Patient Health Questionnaire-9 (≥ 5-point decrease), and 42.2% (n = 35) reported clinically significant improvement on the PTSD Checklist (≥ 10-point decrease). Veterans and clinical staff described the modified collaborative care program positively in qualitative interviews. Discussion: Our findings suggest that a depression collaborative care program can be modified to support treatment of PTSD in primary care. The modified program was acceptable to both veterans and clinical staff and showed potential for positive clinical change in an uncontrolled quality improvement study. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Outcomes of a health informatics technology-supported behavioral activation training for care managers in a collaborative care program.

INTRODUCTION: Health informatics-supported strategies for training and ongoing support may aid the delivery of evidence-based psychotherapies. The objective of this study was to describe the development, implementation, and practice outcomes of a scalable health informatics-supported training program for behavioral activation for patients who screened positive for posttraumatic stress disorder and/or bipolar disorder. METHOD: We trained 34 care managers in 12 rural health centers. They used a registry checklist to document the delivery of 10 behavioral activation skills for 4,632 sessions with 455 patients. Care managers received performance feedback based on registry data. Using encounter-level data reported by care managers, we described the implementation outcomes of patient reach and care manager skill adoption. We used cross-classified multilevel modeling to explore variation in skill delivery accounting for patient characteristics, provider characteristics, and change over time. RESULTS: Care managers engaged 88% of patients in behavioral activation and completed a minimum course for 57%. The average patient received 5.9 skills during treatment, with substantial variation driven more by providers (63%) than patients (29%). Care managers significantly increased the range of skills offered to patients over time. DISCUSSION: The registry-based checklist was a feasible training and support tool for community-based providers to deliver behavioral activation. Providers received data-driven performance feedback and demonstrated skill improvement over time, promoting sustainment. Future research will examine patient-level outcomes. Results underscore the potential public health impact of a simple registry-based skills checklist coupled with a scalable remote training program for evidence-based psychotherapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Behavioral Activation as a Treatment for Posttraumatic Stress Disorder Among Returning Veterans: A Randomized Trial.

OBJECTIVE: Although evidence-based, trauma-processing treatments exist for posttraumatic stress disorder (PTSD), many individuals do not seek out, complete, or fully respond to these treatments, pointing to the need for alternative treatments. In this study, the authors evaluated the effectiveness of behavioral activation therapy modified to address PTSD among veterans. METHODS: In a randomized trial, behavioral activation was compared with treatment as usual (referral to PTSD "standard care") among a sample of 80 veterans of the wars in Iraq and Afghanistan who were enrolled at the U.S. Department of Veterans Affairs (VA) Portland Health Care System and the VA Puget Sound Health Care System. RESULTS: Levels of PTSD symptoms decreased for both groups across posttreatment and at 3-month follow-up as measured by clinical interview and self-report measures. The behavioral activation group had greater improvement on PTSD as evidenced by the self-report measure of symptom severity. Both groups also showed improvement on self-report measures of depression and overall functioning across time, with greater improvement on depression evidenced by the behavioral activation group. Ratings of treatment satisfaction were high for both groups. CONCLUSIONS: Behavioral activation is a promising alternative treatment for PTSD.

Change in social support while participating in behavioral activation for PTSD.

OBJECTIVE: Lack of social support predicts the development, maintenance, and exacerbation of posttraumatic stress disorder (PTSD). Moreover, social dysfunction is associated with recurrent episodes of PTSD care, and detachment/estrangement from others is a strong predictor of suicidal ideation among those with PTSD. Thus, treatments to improve social functioning among those with PTSD are needed. METHOD: Eighty veterans of recent operations in Iraq and Afghanistan participated in a randomized controlled trial comparing treatment as usual to behavioral activation (BA) for PTSD, a treatment that focuses on reducing avoidance behaviors and increasing engagement in valued goals rather than explicitly confronting trauma memories. RESULTS: Mixed-model regression analyses revealed that, accounting for gender, baseline PTSD, and marital status, participants who received BA experienced greater improvements in the number of social supports from baseline to posttreatment compared with those in treatment as usual (F1,96 = 6.29, p = .014). Gains were not maintained at 3-month follow-up, and significant results were not found for satisfaction with social supports. CONCLUSIONS: BA may facilitate an increase in the perceived number of social supports available to veterans with PTSD, but treatment adaptation may be necessary to maintain these gains and to increase satisfaction with social support. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Mental health symptoms and treatment utilization among trauma-exposed college students.

OBJECTIVE: Universities have demonstrated growing awareness of students impacted by interpersonal violence (e.g., sexual and physical assault) and veterans/service-members with combat-related trauma because of their sizable presence on campuses and unique vulnerabilities. This study sought to describe impacts of these two forms of trauma exposure on students' mental health and academic functioning and to compare mental health service utilization among students based on their experiences of trauma exposure. METHOD: To acquire a large, national sample of college students, we examined archival data from the Fall 2015 American College Health Association National College Health Assessment, a yearly, web-based survey which represented a sample of 19,861 students from 40 institutions. RESULTS: Twenty percent of the students had experienced interpersonal victimization in the last 12 months, combat exposure, or both. Compared with other groups, interpersonal violence survivors reported the most negative impacts on mental health and interference with academic performance. Service utilization rates among trauma-exposed students ranged from 52% to 84%, and students who had experienced recent interpersonal violence were the most likely to have received services. CONCLUSIONS: With a national sample, this study confirms that trauma-exposed students report poor mental health. Service utilization is high among this population, but campus-based mental health services appear to remain underutilized. Outreach efforts by student life professionals and campus clinicians targeting demographic subgroups could enhance utilization and accessibility of campus resources. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Relationship satisfaction, PTSD symptom severity, and mental healthcare utilization among OEF/OIF veterans.

Despite the availability of evidence-based PTSD treatments at most facilities within the VA Healthcare System, most Iraq and Afghanistan veterans returning from deployments with posttraumatic stress symptoms do not receive an adequate dose of mental health treatment, prompting the need to identify potential barriers to or facilitators of mental health care utilization. Previous research demonstrated self-reported mental health care utilization in the prior year varies as a function of PTSD symptom severity, and the interaction of PTSD symptom severity and romantic relationship satisfaction (Meis et al., 2010). We extended these findings by objectively measuring the degree of utilization over a 1-year period (i.e., number of sessions attended) in a sample of 130 Iraq and Afghanistan veterans who presented to primary care/deployment health and completed an initial mental health evaluation. Results indicated main and interactive effects of PTSD symptom severity and relationship satisfaction, such that greater PTSD symptom severity was associated with greater utilization at average to high relationship satisfaction (p < .05), but not low relationship satisfaction. Implications for future research and couple/family based interventions for veterans with PTSD are discussed. (PsycINFO Database Record

Longitudinal Examination of Posttraumatic Stress Disorder as a Long-Term Outcome of Iraq War Deployment.

The mental health toll of the Iraq and Afghanistan Wars on military veterans has been considerable, yet little is known about the persistence of these adverse outcomes, especially relative to predeployment status. We prospectively examined posttraumatic stress disorder (PTSD) as a long-term consequence of warzone deployment, integrating data collected from 2003-2014. In the Neurocognition Deployment Health Study, we measured PTSD symptoms in US Army soldiers before and shortly after Iraq War deployment. We used the PTSD Checklist-Civilian Version and a structured clinical interview (i.e., Clinician-Administered PTSD Scale) to reassess PTSD in 598 service members and military veterans a median of 7.9 years (interquartile range, 7.2-8.5 years) after an index Iraq deployment. At long-term follow-up, 24.7% (95% confidence interval (CI): 21.5, 28.4) of participants met the case definition for PTSD, which was an absolute increase of 14.2% from the percentage assessed postdeployment (10.5%; 95% CI: 7.8, 13.7) and of 17.3% from the percentage assessed predeployment (7.4%; 95% CI: 5.5, 9.8). These findings highlight that PTSD is an enduring consequence of warzone participation among contemporary military personnel and veterans. The largest increase in PTSD cases occurred between the postdeployment and long-term follow-up assessments, which suggests that adverse stress reactions cannot necessarily be expected to dissipate over time and actually may increase.

CE: Military Sexual Trauma in Male Service Members.

: The experience of military sexual trauma (MST), which can result from assault, battery, or harassment of a sexual nature, may jeopardize the mental health of service members as well as that of their family members, colleagues, and community members. Although a greater proportion of female than male service members are subjected to MST, the Department of Defense estimates that the absolute numbers of affected men and women, across all ranks and branches of military service, are nearly equal because roughly 85% of military members are men. Little research has explored the effects of MST on men. This article discusses the unique ways in which men may experience MST, and examines how social stereotypes of masculinity, myths surrounding sexual assault, and military culture and structure often influence a man's interpretation of an attack and his likelihood of reporting the incident or seeking treatment. It describes current treatments for MST-related mental health conditions and addresses implications for nurses and other health care professionals.

The efficacy of Focused Acceptance and Commitment Therapy in VA primary care.

Focused Acceptance & Commitment Therapy (FACT) is a brief intervention based on traditional Acceptance and Commitment Therapy (ACT). Although there is a growing body of research on the efficacy of ACT for a variety of populations and disorders, there is little research to date on the use of FACT in group settings. This project is 1 of the first of its kind, as it examines data on psychological flexibility, health and mental health status, and symptom reduction from a 4-week FACT group. Participants in this study were 51 patients who attended this group as part of routine clinical care in a VA integrated primary care and mental health setting. They completed pre- and posttreatment measures of well-being, depression, anxiety, stress, psychological flexibility, and perceptions of physical and mental health functioning. Pre- to posttreatment analyses of variance demonstrated large effects for quality of life, F(1, 51) = 21.29, p < .001, η2 = 0.30, moderate effects for depressive symptoms, F(1, 51) = 11.47, p < .001, η2 = 0.08, and perceptions of mental health functioning (MCS scale), F(1, 51) = 9.67, p = .003, η2 = 0.11, and small effects for perceptions of perceived stress, F(1, 51) = 4.08, p = .04, η2 = 0.03, and physical health functioning (PCS scale), F(1, 51) = 6.60, p = .01, η2 = 0.08. There was a statistical trend for reductions in anxiety, F(1, 51) = 3.29, p = .07, η2 = 0.01, and a nonsignificant effect for psychological flexibility, F(1, 51) = 2.05, p = .16, η2 = 0.04. These data provide initial support for the implementation of a group-based FACT protocol within a VA primary care setting and help to lay a foundation for further, more controlled studies on Group FACT in future research. (PsycINFO Database Record

Military, demographic, and psychosocial predictors of military retention in enlisted army soldiers 12 months after deployment to Iraq.

OBJECTIVE: To examine military, demographic, and psychosocial predictors of military retention following operational deployment. METHODS: Military status 12 months following return from Iraq deployment was assessed via service records in 740 regular active duty Army Soldiers. Potential predictors of military retention were derived from prospectively administered in-person interviews and questionnaires conducted within 3 months following return from Iraq. RESULTS: At 12 months following return from deployment, 18.1% (n = 134) of the sample had separated from military service. Cox proportional hazards analyses, adjusting for demographic, military, and psychosocial predictors, identified several factors that were independently associated with military attrition: less than (vs. equal to or more than) 6 years military experience (hazards ratio [HR], 3.98; 95% CI, 2.12-7.45); unmarried (vs. married) status (HR, 1.51; 95% CI, 1.06-2.16); and lower (vs. higher) levels of self-reported unit support during deployment (HR, 2.22; 95% CI, 1.42-3.47). CONCLUSIONS: Service members early in their career may be especially prone to military attrition. With regard to military retention, our findings suggest that it may be particularly important to develop initiatives that target organizational cohesion and support.

Role of trait shame in the association between posttraumatic stress and aggression among men with a history of interpersonal trauma.

Given the theoretical and empirical associations among posttraumatic stress, shame, and interpersonal aggression, this study examined whether trait shame accounts for the associations between posttraumatic stress and aggressive behavior in a sample of 103 men with a history of interpersonal trauma. Results indicated that trait shame accounted for the associations of posttraumatic stress with the variety of both physically and psychologically aggressive behavior, as well as with the frequency of physical aggression. This study also examined trait guilt, given its conceptual relationship to both shame and posttraumatic stress; unlike trait shame, trait guilt did not account for the association between posttraumatic stress and the variety of physically aggressive acts. Additionally, although trait guilt reduced the association between posttraumatic stress and the frequency of physical aggression, the indirect path including guilt was nonsignificant. Taken together, the present study supports existing theories suggesting that shame, but not guilt, may contribute to aggressive behavior, especially among individuals with histories of traumatic exposure.

PTSD and depression symptoms are associated with binge eating among US Iraq and Afghanistan veterans.

OBJECTIVE: US Iraq and Afghanistan Veterans with post-traumatic stress disorder (PTSD) and depression are at increased risk for obesity. Understanding the contribution of health behaviors to this relationship will enhance efforts to prevent and reduce obesity. Therefore, we examined the association of PTSD and depression symptoms with binge eating, a risk factor for obesity, among Iraq/Afghanistan Veterans. METHOD: Iraq/Afghanistan Veterans were assessed at intake to the VA Puget Sound Healthcare System-Seattle post-deployment clinic (May 2004-January 2007). The Patient Health Questionnaire was used to measure depression and binge eating symptoms, and the PTSD Checklist-Military Version assessed PTSD symptoms. RESULTS: The majority of the sample (N=332) was male (91.5%) and Caucasian (72.6%), with an average age of 31.1 (SD=8.5) years; 16.3% met depression screening criteria, 37.8% met PTSD screening criteria, and 8.4% met binge eating screening criteria. In adjusted models, those meeting depression (odds ratio (OR)=7.53; 95% CI=2.69, 21.04; p<.001) and PTSD (OR=3.37; 95% CI=1.34, 8.46; p=.01) screening criteria were more likely to meet binge eating screening criteria. Continuous measures of PTSD and depression symptom severity were also associated with meeting binge eating screening criteria (ps<.05). CONCLUSION: PTSD and depression are common conditions among Iraq/Afghanistan Veterans. In the present study, PTSD and depression symptoms were associated with meeting binge eating screening criteria, identifying a possible pathway by which psychiatric conditions lead to disproportionate burden of overweight and obesity in this Veteran cohort. Tailored dietary behavior interventions may be needed for Iraq/Afghanistan Veterans with co-morbid obesity and psychiatric conditions.

A pilot trial of telephone-based collaborative care management for PTSD among Iraq/Afghanistan war veterans.

BACKGROUND: Collaborative care and care management are cornerstones of Primary Care-Mental Health Integration (PC-MHI) and have been shown to reduce depressive symptoms. Historically, the standard of Veterans Affairs (VA) collaborative care was referring patients with posttraumatic stress disorder (PTSD) to specialty care. Although referral to evidence-based specialty care is ideal, many veterans with PTSD do not receive such care. To address this issue and reduce barriers to care, VA currently recommends veterans with PTSD be offered treatment within PC-MHI as an alternative. The current project outlines a pilot implementation of an established telephone-based collaborative care model-Translating Initiatives for Depression into Effective Solutions (TIDES)-adapted for Iraq/Afghanistan War veterans with PTSD symptoms (TIDES/PTSD) seen in a postdeployment primary care clinic. MATERIALS AND METHODS: Structured medical record extraction and qualitative data collection procedures were used to evaluate acceptability, feasibility, and outcomes. RESULTS: Most participants (n=17) were male (94.1%) and white (70.6%). Average age was 31.2 (standard deviation=6.4) years. TIDES/PTSD was successfully implemented within PC-MHI and was acceptable to patients and staff. Additionally, the total number of care manager calls was positively correlated with number of psychiatry visits (r=0.63, p<0.05) and amount of reduction in PTSD symptoms (r=0.66, p<0.05). Overall, participants in the pilot reported a significant reduction in PTSD symptoms over the course of the treatment (t=2.87, p=0.01). CONCLUSIONS: TIDES can be successfully adapted and implemented for use among Iraq/Afghanistan veterans with PTSD. Further work is needed to test the effectiveness and implementation of this model in other sites and among veterans of other eras.

The Effects of Alcohol Problems, PTSD, and Combat Exposure on Nonphysical and Physical Aggression Among Iraq and Afghanistan War Veterans.

Aggression among combat veterans is of great concern. Although some studies have found an association between combat exposure and aggressive behavior following deployment, others conclude that aggression is more strongly associated with symptoms of posttraumatic stress disorder (PTSD), and that alcohol misuse may influence this association. Many of these studies have assessed aggression as a single construct, whereas the current study explored both nonphysical aggression only and physical aggression in a sample of Iraq and Afghanistan war veterans (N = 337; 91% male). We found that alcohol problems interacted with PTSD symptom severity to predict nonphysical aggression only. At low levels of PTSD symptoms, veterans with alcohol problems were more likely to perpetrate nonphysical aggression only, as compared with no aggression, than veterans without an alcohol problem. There was no difference in the likelihood of nonphysical aggression only between those with and without alcohol problems at high levels of PTSD symptoms. The likelihood of nonphysical aggression only, as compared with no aggression, was also greater among younger veterans. Greater combat exposure and PTSD symptom severity were associated with an increased likelihood of perpetrating physical aggression, as compared with no aggression. Ethnic minority status and younger age were also associated with physical aggression, as compared with no aggression. Findings suggest that a more detailed assessment of veterans' aggressive behavior, as well as their alcohol problems and PTSD symptoms, by researchers and clinicians is needed in order to determine how best to intervene.

Unique PTSD clusters predict intention to seek mental health care and subsequent utilization in US veterans with PTSD symptoms.

Many veterans return from deployment with posttraumatic stress disorder (PTSD), but most attend only a limited number of mental health care visits. Although global PTSD relates to seeking mental health care, it is unclear whether specific features of PTSD inform the low rates of mental health care utilization. This study examined PTSD cluster severities of avoidance, reexperiencing, dysphoria, and hyperarousal as predictors of intention to seek mental health care and prospective treatment utilization. US veterans with at least subthreshold PTSD (N = 189) completed a PTSD symptom measure and indicated whether they intended to seek mental health care. Prospective Department of Veterans Affairs mental health care utilization was extracted from the medical record. At the bivariate level, each cluster was positively associated with a positive intention to seek mental health care and prospective treatment utilization. In multivariate models, however, dysphoria severity (OR = 1.16, 95% CI [1.06, 1.26]) was uniquely and positively correlated with intention to seek mental health care, whereas higher avoidance severity (IRR = 0.86, 95% CI [0.76, 0.98]) predicted lower treatment utilization, and higher reexperiencing severity (IRR = 1.07, 95% CI [1.01, 1.14]) predicted greater treatment utilization. It is critical to tailor interventions to target specific features of PTSD and to meet patients where they are.

A survey of perceived barriers and attitudes toward mental health care among OEF/OIF veterans at VA outpatient mental health clinics.

OBJECTIVE: In an effort to improve our understanding of perceived treatment barriers among veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) relative to other era veterans, the current study examined veteran attitudes and beliefs about mental health treatment and treatment-seeking, and perceived patient and institution-level logistical barriers to care. METHOD: A survey was conducted among 434 Combat veterans seeking care in nine Veterans Affairs mental health care outpatient clinics. RESULTS: When compared to Vietnam and Gulf War veterans, OEF/OIF veterans were significantly more likely to endorse negative treatment attitudes as possible barriers to care. OEF/OIF veterans were also more likely than Vietnam veterans to endorse conflicting work demands as a potential barrier, although this was the only logistical barrier for which OEF/OIF veterans' responses differed significantly from those of veterans of other eras. Among OEF/OIF veterans, older veterans were more likely than younger veterans to endorse barriers related to cost and time commitments. CONCLUSIONS: These findings suggest an important role for outreach and engagement strategies that address attitudinal barriers to treatment utilization among veteran populations.