0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

Articles   |    
PTSD Treatment for Soldiers After Combat Deployment: Low Utilization of Mental Health Care and Reasons for Dropout
Charles W. Hoge, M.D.; Sasha H. Grossman, B.A.; Jennifer L. Auchterlonie, M.S.; Lyndon A. Riviere, Ph.D.; Charles S. Milliken, M.D.; Joshua E. Wilk, Ph.D.
Psychiatric Services 2014; doi: 10.1176/appi.ps.201300307
View Author and Article Information

The authors are with the Center for Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland (e-mail: charles.hoge@us.army.mil).

Copyright © 2014 by the American Psychiatric Association

Abstract

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.

Abstract Teaser
Figures in this Article

Your Session has timed out. Please sign back in to continue.
Sign In Your Session has timed out. Please sign back in to continue.
Sign In to Access Full Content
 
Username
Password
Sign in via Athens (What is this?)
Athens is a service for single sign-on which enables access to all of an institution's subscriptions on- or off-site.
Not a subscriber?

Subscribe Now/Learn More

PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing PsychiatryOnline@psych.org or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Anchor for Jump
Table 1Demographic characteristics of two army study groups after service in Afghanistana
Table Footer Note

a Percentages adjusted for missing values. Percentages may not sum to 100 because of rounding.

Table Footer Note

b PDHA, Post-Deployment Health Assessment

Anchor for Jump
Table 2Total outpatient visits involving PTSD diagnosis over a 12-month perioda
Table Footer Note

a N=1,962 soldiers from the Army cohort who completed the Post-Deployment Health Assessment and had at least one visit providing a PTSD diagnosis

Anchor for Jump
Table 3Health care utilization by all soldiers responding to the infantry brigade survey and respondents screening positive for PTSD
Table Footer Note

a Percentages were adjusted for missing values.

Table Footer Note

b For all soldiers (N=402), the median number of mental health visits in six months was 2, interquartile range 1–4; for those with a positive PTSD screen (N=95), the median number of mental health visits was 4, interquartile range 2–7.

Anchor for Jump
Table 4Reasons infantry soldiers reported for dropping out of mental health care
Table Footer Note

a Items are presented verbatim and in the same order as on the survey. Each item was a separate question with a “yes/no/NA” (not applicable) response format. These items were preceded by a yes-no stem question that asked, “Did you start receiving mental health treatment anytime in the PAST SIX MONTHS, but stopped or dropped out before completing the treatment?” This was followed by, “If yes, what were your reasons for dropping out?”

Table Footer Note

b PCS, soldier had a permanent change of station (moved to another post)

Anchor for Jump
Table 5Reasons 23 soldiers with PTSD reported for dropping out of mental health care
Table Footer Note

a Items are presented in the same order as on the survey (yes/no/NA [not applicable] responses). The yes-no stem question was, “Did you start receiving mental health treatment anytime in the PAST SIX MONTHS, but stopped or dropped out before completing the treatment?” This was followed by, “If yes, what were your reasons for dropping out?”

Table Footer Note

b PCS, soldier had a permanent change of station (moved to another post)

+

References

Hoge  CW;  Castro  CA;  Messer  SC  et al:  Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.  New England Journal of Medicine 351:13–22, 2004
[CrossRef] | [PubMed]
 
Hoge  CW;  Auchterlonie  JL;  Milliken  CS:  Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan.  JAMA 295:1023–1032, 2006
[CrossRef] | [PubMed]
 
Kok  BC;  Herrell  RK;  Thomas  JL  et al:  Posttraumatic stress disorder associated with combat service in Iraq or Afghanistan: reconciling prevalence differences between studies.  Journal of Nervous and Mental Disease 200:444–450, 2012
[CrossRef] | [PubMed]
 
Thomas  JL;  Wilk  JE;  Riviere  LA  et al:  Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq.  Archives of General Psychiatry 67:614–623, 2010
[CrossRef] | [PubMed]
 
McKibben  JBA;  Fullerton  CS;  Gray  CL  et al:  Mental health service utilization in the US Army.  Psychiatric Services 64:347–353, 2013
[CrossRef] | [PubMed]
 
Sareen  J;  Cox  BJ;  Afifi  TO  et al:  Combat and peacekeeping operations in relation to prevalence of mental disorders and perceived need for mental health care: findings from a large representative sample of military personnel.  Archives of General Psychiatry 64:843–852, 2007
[CrossRef] | [PubMed]
 
Kim  PY;  Thomas  JL;  Wilk  JE  et al:  Stigma, barriers to care, and use of mental health services among active duty and National Guard soldiers after combat.  Psychiatric Services 61:582–588, 2010
[CrossRef] | [PubMed]
 
Schell  TL;  Marshall  GN:  Survey of individuals previously deployed for OEF/OIF; in  Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery . Edited by Tanielian  T;  Jaycox  LH.  Santa Monica, Calif,  RAND, 2008
 
Lu  MW;  Duckart  JP;  O’Malley  JP  et al:  Correlates of utilization of PTSD specialty treatment among recently diagnosed veterans at the VA.  Psychiatric Services 62:943–949, 2011
[PubMed]
 
Spoont  MR;  Murdoch  M;  Hodges  J  et al:  Treatment receipt by veterans after a PTSD diagnosis in PTSD, mental health, or general medical clinics.  Psychiatric Services 61:58–63, 2010
[CrossRef] | [PubMed]
 
Harpaz-Rotem  I;  Rosenheck  RA:  Serving those who served: retention of newly returning veterans from Iraq and Afghanistan in mental health treatment.  Psychiatric Services 62:22–27, 2011
[CrossRef] | [PubMed]
 
Stecker  T;  Fortney  JC;  Hamilton  F  et al:  An assessment of beliefs about mental health care among veterans who served in Iraq.  Psychiatric Services 58:1358–1361, 2007
[CrossRef] | [PubMed]
 
Kim  PY;  Britt  TW;  Klocko  RP  et al:  Stigma, negative attitudes about treatment, and utilization of mental health care among soldiers.  Military Psychology 23:65–81, 2011
[CrossRef]
 
Brown  MC;  Creel  AH;  Engel  CC  et al:  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, 2011
[CrossRef] | [PubMed]
 
Pietrzak  RH;  Johnson  DC;  Goldstein  MB  et al:  Perceived stigma and barriers to mental health care utilization among OEF-OIF veterans.  Psychiatric Services 60:1118–1122, 2009
[CrossRef] | [PubMed]
 
Sudom  K;  Zamorski  M;  Garber  B:  Stigma and barriers to mental health care in deployed Canadian Forces personnel.  Military Psychology 24:414–431, 2012
[CrossRef]
 
Milliken  CS;  Auchterlonie  JL;  Hoge  CW:  Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war.  JAMA 298:2141–2148, 2007
[CrossRef] | [PubMed]
 
Gravely  AA;  Cutting  A;  Nugent  S  et al:  Validity of PTSD diagnoses in VA administrative data: comparison of VA administrative PTSD diagnoses to self-reported PTSD Checklist scores.  Journal of Rehabilitation Research and Development 48:21–30, 2011
[CrossRef] | [PubMed]
 
Frayne  SM;  Miller  DR;  Sharkansky  EJ  et al:  Using administrative data to identify mental illness: what approach is best? American Journal of Medical Quality 25:42–50, 2010
[CrossRef] | [PubMed]
 
Blanchard  EB;  Jones-Alexander  J;  Buckley  TC  et al:  Psychometric properties of the PTSD Checklist (PCL).  Behaviour Research and Therapy 34:669–673, 1996
[CrossRef] | [PubMed]
 
Terhakopian  A;  Sinaii  N;  Engel  CC  et al:  Estimating population prevalence of posttraumatic stress disorder: an example using the PTSD Checklist.  Journal of Traumatic Stress 21:290–300, 2008
[CrossRef] | [PubMed]
 
Warner  CH;  Appenzeller  GN;  Grieger  TA  et al:  Importance of anonymity to encourage honest reporting in mental health screening after combat deployment.  Archives of General Psychiatry 68:1065–1071, 2011
[CrossRef] | [PubMed]
 
Wang  PS;  Lane  M;  Olfson  M  et al:  Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication.  Archives of General Psychiatry 62:629–640, 2005
[CrossRef] | [PubMed]
 
Clinical Practice Guideline for Management of Post-Traumatic Stress, Version 2.0. Washington, DC, US Department of Veteran Affairs, US Department of Defense, 2010
 
Hoge  CW:  Interventions for war-related posttraumatic stress disorder: meeting veterans where they are.  JAMA 306:549–551, 2011
[CrossRef] | [PubMed]
 
Edlund  MJ;  Wang  PS;  Berglund  PA  et al:  Dropping out of mental health treatment: patterns and predictors among epidemiological survey respondents in the United States and Ontario.  American Journal of Psychiatry 159:845–851, 2002
[CrossRef] | [PubMed]
 
Swift  JK;  Greenberg  RP;  Whipple  JL  et al:  Practice recommendations for reducing premature termination in therapy.  Professional Psychology: Research and Practice 43:379–387, 2012
[CrossRef]
 
Trusz  SG;  Wagner  AW;  Russo  J  et al:  Assessing barriers to care and readiness for cognitive behavioral therapy in early acute care PTSD interventions.  Psychiatry 74:207–223, 2011
[PubMed]
 
Arkowitz  H;  Westra  HA;  Miller  WH  et al (eds):  Motivational Interviewing in the Treatment of Psychological Problems .  New York,  Guilford, 2008
 
Slagle  DM;  Gray  MJ:  The utility of motivational interviewing as an adjunct to exposure therapy in the treatment of anxiety disorders.  Professional Psychology: Research and Practice 38:329–337, 2007
[CrossRef]
 
Murphy  RT;  Thompson  KE;  Murray  M  et al:  Effect of a motivation enhancement intervention on veterans’ engagement in PTSD treatment.  Psychological Services 6:264–278, 2009
[CrossRef]
 
Institute of Medicine:  Substance Use Disorders in the US Armed Forces .  Washington, DC,  National Academies Press, 2012
 
Hoge  CW:  Once a Warrior Always a Warrior: Navigating the Transition From Combat to Home, Including Combat Stress, PTSD, and mTBI .  Guilford, Conn,  Globe Pequot Press, 2010
 
Miller  SD;  Duncan  BL;  Brown  J  et al:  Using formal client feedback to improve retention and outcome: making ongoing, real-time assessment feasible.  Journal of Brief Therapy 5:5–22, 2006
 
Warner  CH;  Appenzeller  GN;  Parker  JR  et al:  Effectiveness of mental health screening and coordination of in-theater care prior to deployment to Iraq: a cohort study.  American Journal of Psychiatry 168:378–385, 2011
[CrossRef] | [PubMed]
 
Koepsell  TD;  Zatzick  DF;  Rivara  FP:  Estimating the population impact of preventive interventions from randomized trials.  American Journal of Preventive Medicine 40:191–198, 2011
[CrossRef] | [PubMed]
 
Zatzick  DF;  Galea  S:  An epidemiologic approach to the development of early trauma focused intervention.  Journal of Traumatic Stress 20:401–412, 2007
[CrossRef] | [PubMed]
 
References Container
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Web of Science® Times Cited: 2

Related Content
See Also...
Articles
Books
DSM-5™ Clinical Cases > Chapter 7.  >
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 34.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 65.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 65.  >
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 62.  >
Topic Collections
Psychiatric News
APA Guidelines
PubMed Articles