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Stigma, Barriers to Care, and Use of Mental Health Services Among Active Duty and National Guard Soldiers After Combat
Paul Y. Kim, M.A.; Jeffrey L. Thomas, Ph.D.; Joshua E. Wilk, Ph.D.; Carl A. Castro, Ph.D.; Charles W. Hoge, M.D.
Psychiatric Services 2010; doi: 10.1176/appi.ps.61.6.582
View Author and Article Information

Mr. Kim, Dr. Thomas, Dr. Wilk, and Dr. Hoge are affiliated with the Department of Military Psychiatry, Walter Reed Army Institute of Research, 503 Robert Grant Ave., Silver Spring, MD 20910 (e-mail: paul.kim@amedd.army.mil). Dr. Castro is with the U.S. Army Medical Research and Materiel Command, Frederick, Maryland.

Abstract

Objective: This study examined rates of utilization of mental health care among active duty and National Guard soldiers with mental health problems three and 12 months after they returned from combat in Iraq. Stigma and barriers to care were also reported for each component (active duty and National Guard). Methods: Cross-sectional, anonymous surveys were administered to 10,386 soldiers across both time points and components. Mean scores from 11 items measuring stigma and barriers to care were computed. Service utilization was assessed by asking soldiers whether they had received services for a mental health problem from a mental health professional, a medical doctor, or the Department of Veterans Affairs in the past month. Risk of mental problems was measured using the Patient Health Questionnaire, the PTSD Checklist, and items asking about aggressive behaviors and "stress, emotional, alcohol, or family" problems within the past month. Results: A higher proportion of active duty soldiers than National Guard soldiers reported at least one type of mental health problem at both three months (45% versus 33%) and 12 months (44% versus 35%) postdeployment. Among soldiers with mental health problems, National Guard soldiers reported significantly higher rates of mental health care utilization 12 months after deployment, compared with active duty soldiers (27% versus 13%). Mean stigma scores were higher among active duty soldiers than among National Guard soldiers. Conclusions: Active duty soldiers with a mental health problem had significantly lower rates of service utilization than National Guard soldiers and significantly higher endorsements of stigma. Current and future efforts to improve care for veterans should work toward reducing the stigma of receiving mental health care. (Psychiatric Services 61:572–588, 2010)

Abstract Teaser
Figures in this Article

Iraq war veterans report high rates of mental problems postdeployment (1) that increase in the months after return (2,3). In a large longitudinal study of soldiers returning from Iraq and Afghanistan, Milliken and colleagues (3) reported significantly higher rates of mental health concerns three to six months after deployment, compared with rates reported immediately after deployment. They also found that although National Guard and active duty soldiers reported similar rates of mental health concerns immediately after deployment, National Guard soldiers reported higher rates than active duty soldiers three to six months later.

Despite the high estimated prevalence of mental problems after combat, research has shown that only half of the soldiers with a mental problem reported seeking care within a year (4,5). Presumably, the low rates of service utilization are due to stigma and perceived barriers to care. Hoge and colleagues (1) found that soldiers who met screening criteria for mental problems were twice as likely as soldiers who did not meet screening criteria to report feelings of stigma. Research on stigma in civilian populations asserts that individuals who perceive the stigmatizing behaviors of others as legitimate will have lower self-esteem (6). This belief and internalization of stigmatizing behaviors is likely to reduce treatment seeking by soldiers with mental illness (7,8). Even if soldiers have not internalized stigma, specific barriers to care, such as lack of time or transportation difficulties, might also prevent soldiers from seeking treatment. Barriers to care have been found to exacerbate the relationship between work stressors and depression among soldiers (9). Furthermore, differences in mental health referral rates between active duty and National Guard soldiers have been reported (3). This survey-based study examined rates of mental health problems, mental health care utilization, stigma, and organizational barriers to care between active duty and National Guard component soldiers at three and 12 months postdeployment. We are not aware of any existing studies that have assessed risk of mental problems, perceptions of stigma and barriers to care, or utilization rates at 12 months.

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Sample

A total of 15,918 anonymous surveys were received from both components (active duty and National Guard) and from both time points (three and 12 months). Of these, 10,386 reported being deployed to Iraq and were included in the analysis. All data were collected cross-sectionally from multiple brigade combat teams between December 2003 and October 2007. A total of 1,510 National Guard soldiers and 4,502 active duty soldiers were surveyed three months after their first deployment to Iraq. An additional 758 National Guard soldiers and 3,616 active duty soldiers were surveyed 12 months after their first deployment. Because a majority of soldiers remain in the unit from which they were deployed for the next 12 months, it is likely that many of the same soldiers completed surveys at both time points. In each of the units at both time points, unit personnel reported that 27,005 soldiers were available to participate in the study. This yielded an overall response rate of 59% (N=15,918 of 27,005), which is consistent with other military population-based studies (1,10). Reasons for not being able to attend the survey session include work-related duties and being on leave, ill, or on temporary duty elsewhere. Among those who were present for the study, approximately 94% to 99% of soldiers from both time points and components completed any part of the paper-and-pencil survey. Soldiers were given a complete description of the study. Those who elected to complete the survey provided their consent under a protocol approved by the institutional review board at the Walter Reed Army Institute of Research.

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Measures

Stigma was measured with a six-item scale assessing common concerns about receiving mental health services (for example, "I would be seen as weak"). These, as well as the items on barriers to care, were originally developed by Hoge and colleagues (1) and have been used in recent studies (9,11). Each item was measured on a 5-point scale (1, strongly disagree, to 5, strongly agree). Cronbach's alpha for this scale was .95.

Organizational barriers to care were measured with the same 5-point scale and included five items (for example, "I don't know where to get help"). These items were originally developed by Hoge and colleagues (1) and have been used in recent studies (9,11). Cronbach's alpha for this scale was .86.

Service utilization rates were measured by asking respondents whether they had received mental health services for a stress, emotional, alcohol, or family problem from either a mental health professional at a military or civilian facility or a general medical doctor at a military or civilian facility. An additional utilization measure regarding mental health care from Department of Veterans Affairs (VA) health facilities or veteran centers was included for National Guard soldiers. Soldiers who indicated that they had received any one of these services at least once in the past month were categorized as utilizing care.

Soldiers were identified as being at risk of psychiatric problems if they had screened positive for major depressive disorder, severe anxiety symptoms, or posttraumatic stress disorder (PTSD); if they reported frequent aggressive behaviors; or if they reported any overall problems related to relationships, distress, or alcohol at the moderate or severe level (1).

Depression levels were measured with the Patient Health Questionnaire (PHQ) (12), a standard approach in recent studies of soldiers (1,13,14). Soldiers who indicated that they had been bothered by at least five of nine depression symptoms for more than half the days in the past month and reported either "little interest or pleasure in doing things" or "feeling down, depressed, or hopeless" more than half the days in the past month were considered to screen positive for depression. Additionally, in order to screen positive, respondents needed to endorse that their depression symptoms made it very or extremely difficult to function at work or home or to get along with other people.

Severe anxiety was measured using six items from the PHQ. Respondents endorsing three of the six items for more than half the days within the past month and indicating that they feel bad about themselves—or that they are a failure or have let themselves or their family down for more than half the days in the past month—were considered to have severe anxiety symptoms. As with the depression measure, respondents also had to report that their anxiety symptoms made it very or extremely difficult to function at work or home or in getting along with other people.

PTSD was assessed with the 17-item PTSD Checklist (PCL) (15,16), a well-validated measure of the severity of symptoms related to stressful experiences that follows current DSM-IV guidelines (17). Soldiers who reported that they had been bothered moderately by at least one intrusion symptom, three avoidance symptoms, and two hyperarousal symptoms within the past month and also scored 50 or higher on the overall PCL scale screened positive for PTSD (18).

Aggressive behaviors were assessed with three items previously used by Killgore and colleagues (19). Respondents who reported either "getting angry with someone" or that they "kicked or smashed something" at least three times in the past month or who reported "threatening someone with violence" at least twice in the past month or "getting into a fight" at least once in the past month were considered to be at risk of mental problems.

Respondents were also asked whether they had experienced a stress, emotional, alcohol, or family problem within the past month. Those who indicated a moderate or severe problem were considered to be at risk of mental problems. This measure has been used in a similar manner in a previous study examining military mental health (1).

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Analysis

Chi square tests were conducted to test for differences in rates of risk of mental problems, service utilization, and endorsement of stigma and barriers-to-care items between components. Independent-samples t tests were conducted to compare mean stigma and barriers-to-care scores between components. Logistic regression analyses were used to predict the effect of component status on service utilization of any type of care, as well as for each of the four specific types of care. Stigma, sex, and rank were entered as controls. All analyses were produced with SPSS software, version 16 (20).

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Demographic characteristics

Soldiers from both components were demographically similar at both time points, although National Guard soldiers were older (Table 1). These demographic characteristics are similar to those of soldiers included in previous postdeployment studies (1,3). To compare the demographic characteristics of our sample with the demographic characteristics of all veterans returning from Iraq, we also included demographic information from the Defense Medical Surveillance System in Table 1 (10).

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Risk of mental problems

Table 2 displays the rates of overall risk of mental problems and specific diagnoses among active duty and National Guard soldiers at both time points. Reports of overall risk of mental problems remained relatively stable between time points among both active duty (45% [N=2,023 of 4,482] to 44% [N=1,566 of 3,571]) and National Guard soldiers (33% [N=497 of 1,497] to 35% [N=267 of 754]). Specific diagnoses tended to increase at 12 months in both components, although this increase was higher among National Guard soldiers. Active duty soldiers reported higher rates of mental problems than National Guard soldiers at both time points.

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Stigma and barriers to care

Table 3 shows rates of stigma and barriers to care and changes over time for soldiers reporting mental health problems. Overall mean scores for stigma and barriers to care are also reported. Among both active duty and National Guard soldiers, there were no significant differences over time in either stigma or barriers to care.

Active duty soldiers at risk of mental problems reported significantly stronger feelings of stigma, on average, compared with National Guard soldiers at both three months postdeployment (3.08±1.04 versus 2.65±.97) (t=8.25, df=2,352, p<.001) and 12 months postdeployment (3.08±1.06 versus 2.67±1.01) (t=5.65, df=1,696, p<.001) (Table 3). This same pattern was observed across all six of the stigma items when examined independently (Table 3) and also when looking at only those with depression, anxiety, or PTSD (excluding those with emotional, alcohol, or anger problems).

Active duty soldiers' average scores on barriers-to-care items were similar to those of National Guard soldiers at both three months postdeployment and 12 months postdeployment (Table 3). Analyses of individual items on barriers to care produced more striking contrasts. At three months, active duty soldiers were significantly more likely than National Guard soldiers to report difficulty scheduling an appointment (28% [N=517 of 1866] versus 18% [N=84 of 470], p<.001). Active duty soldiers were also significantly more likely to report difficulty getting time off of work to schedule an appointment (34% [N=633 of 1,872] versus 20% [N=95 of 468], p<.001). National Guard soldiers, on the other hand, were more likely than active duty soldiers to report that mental health care costs too much money (22% [N=105 of 470] versus 15% [N=271 of 1,865], p<.001). These items were rated significantly higher among active duty soldiers at 12 months as well. Additional analyses comparing only those with depression, anxiety, or PTSD (excluding those with emotional, alcohol, or anger problems) replicated these patterns.

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Service utilization

Table 4 shows changes in rates of utilization of mental health care between time points among soldiers reporting any mental health problem. In assessing specific types of provider care, active duty soldiers showed moderate increases in rates of utilization at 12 months.

National Guard soldiers' use of mental health providers increased for each type of care over the study period, particularly in their use of care from the VA, which increased from 11% (N=49 of 466) to 18% (N=45 of 253). Overall, use of any type of provider care for National Guard soldiers increased substantially from 17% (N=81 of 463) to 27% (N=68 of 255). Additional analyses comparing only those with depression, anxiety, or PTSD (excluding those with emotional, alcohol, or anger problems) replicated these patterns.

Among those who reported a mental health problem, at three months, National Guard soldiers were significantly more likely than active duty soldiers to have used mental health care in the past month (17% [N=81 of 463] versus 13% [N=247 of 1,871], p<.05) and 12 months postdeployment (27% [N=68 of 255] versus 13% [N=187 of 1,408], p<.001) (Table 4). After the analyses controlled for stigma, sex, and rank, National Guard soldiers reported significantly higher odds of seeking any type of care at both time points, compared with active duty soldiers (Table 4).

Regarding specific types of care used at three months, active duty soldiers were significantly more likely than National Guard soldiers to see mental health professionals at military facilities at three months (10% [N=198 of 1,899] versus 5% [N=25 of 468], p<.001). This trend persisted even after the analysis controlled for stigma, sex, and rank. At three months, compared with active duty soldiers, National Guard soldiers were more likely to receive care from mental health professionals at civilian facilities (7% [N=34 of 468] versus 3% [N=66 of 1,886], p<.01) and from general medical care providers at a civilian facility (7% [N=33 of 467] versus 2% [N=47 of 1,895], p<.001). At 12 months National Guard soldiers were twice as likely as active duty soldiers to see a mental health professional at a civilian facility (10% [N=27 of 258] versus 5% [N=69 of 1,428], p<.01) and general medical doctor at a civilian facility (8% [N=21 of 255] versus 4% [N=56 of 1,444], p<.05). The odds of receiving these types of care persisted after the analysis controlled for stigma, sex, and rank.

Research has shown that the timing of mental health assessments among soldiers returning from combat is important; mental health prevalence rates are higher at three to four months postdeployment (2,3). This study found that beyond three months there was no appreciable increase in mental health problems. However, there were clear differences between active duty and the National Guard in perceptions of stigma, barriers to care, and how mental health care is utilized.

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Rates of mental problems

At both three and 12 months, compared with National Guard soldiers, active duty soldiers reported higher overall risk of mental problems, as well as specific mental problems, such as depression, anxiety, aggression, and family and emotional problems. These results are not consistent with a recent study showing that National Guard soldiers had higher rates of mental health problems three to six months postdeployment, compared with active duty soldiers (3). These differences may be attributed to the fact that overall risk of mental problems was measured by using different scales than in the previous study. Furthermore, our surveys, unlike in the study by Milliken and colleagues (3), were conducted anonymously, rather than as part of a nonanonymous postdeployment health assessment that could result in clinical referral. Previous research has shown that anonymous studies have resulted in higher rates of endorsement of sensitive items, such as questions related to aggressive or violent behavior, compared with nonanonymous studies (21).

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Stigma and barriers to care

This is the first study, to our knowledge, that explored rates of stigma and barriers to care between components at 12 months. Active duty soldiers consistently reported higher perceptions of stigma than National Guard soldiers at three and 12 months postdeployment. Across the majority of stigma items, active duty respondents endorsed stigma twice as often as their National Guard counterparts.

It is not entirely clear why National Guard soldiers would report lower levels of stigma than active duty soldiers. There may be differences in the organizational culture that might influence how soldiers in different components perceive and interpret mental illness and mental health care (22). Because National Guard soldiers are not as fully integrated into the Army culture and daily life as active duty soldiers, fear of repercussions from their leadership and unit may be attenuated. Although these results are not causal, they provide complementary support for a growing body of literature that has examined the connection between elevated feelings of stigma and decreased utilization of mental health care among returning veterans with mental health problems (1,4,23,24).

In regard to barriers to care, we found that a significantly higher proportion of active duty soldiers reported concerns about difficulties scheduling an appointment and getting time off work for treatment. It is unclear whether participants interpreted this item to refer to strictly organizational difficulties, personal difficulties (for example, feelings of stigma), or both. On the other hand, National Guard soldiers were more likely to report concerns regarding the high cost of mental health care. This sentiment corresponds to their concerns regarding VA health care benefits, which, at that time, would expire only a year after the 12-month postdeployment survey was taken.

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Service utilization

This study is unique in that it provides an examination of rates of the use of mental health care services for those at risk of mental problems 12 months postdeployment for both active duty and National Guard soldiers. Among National Guard soldiers with mental health problems, use of mental health care increased sharply between the two time points. By 12 months postdeployment, National Guard soldiers were almost twice as likely as active duty soldiers to receive some type of mental health care. Logistic regression analyses confirmed that component status not only covaried with but also predicted treatment seeking, after analyses controlled for stigma, gender, and rank.

These data may reflect National Guard soldiers' concerns that their Army-sponsored health insurance benefits are not continuous, which may provide a sense of urgency to seek out treatment while they are still insured. At 12 months, National Guard soldiers' TRICARE health insurance benefits would have already expired (www.tricare.mil/factsheets/viewfactsheet.cfm?id=317). At the time these data were collected, National Guard soldiers were eligible for VA health care benefits for only two years after their return from deployment (Veterans Health Administration Directive 2002-049). After the National Defense Authorization Act was passed in 2008 (www.va.gov/healtheligibility/Library/pubs/CombatVet/CombatVet.pdf), National Guard soldiers became eligible for VA health care benefits for five years after their return from deployment. Future research is needed to investigate the effects of this policy change on service utilization rates of National Guard soldiers.

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Limitations

First, the cross-sectional design of this study prevents causal statements about stigma and utilization. Longitudinal data are needed to more adequately investigate the prospective effect of stigma beliefs on the utilization of care. Second, because self-report surveys were used, the rates of utilization could be exaggerated or underreported. However, because of the anonymity of the survey, we feel confident that the rates of mental health problems and utilization will reflect an honest and accurate response. Finally, our enrollment procedures may have produced a selection bias in our sample. Our procedures did not permit the inclusion of the severely wounded or soldiers unable to participate because of misconduct. Thus our sample was limited to nonhospitalized soldiers in good standing.

This is the first study to compare perceptions of stigma between active duty and National Guard soldiers and may inform future policy to address concerns of inadequate access to mental health care, particularly among active duty soldiers. Our findings uncover stronger feelings of stigma and organizational barriers to care among active duty soldiers than among National Guard soldiers. Continued efforts to reduce stigma and provide access to mental health care will enable service members to recover from the wounds of war.

This study was supported by the Military Operational Medicine Research Program, U.S. Army Medical Research and Materiel Command and by core departmental funding. The authors thank Paul Bliese, Ph.D., for helpful comments on draft versions of this article as well as the Land Combat Study team for their support with the data collection. Material has been reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation or publication. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting true views of the Department of the Army or the Department of Defense.

The authors report no competing interests.

Hoge CW, Castro CA, Messer SM, et al: Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351:13–22, 2004
 
Bliese, PD, Wright KM, Adler BA, et al: Timing of postcombat mental health assessments. Psychological Services 4:141–148, 2007
 
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
 
Fikretoglu D, Guay S, Pedlar D, et al: Twelve month use of mental health services in a nationally representative, active military sample. Medical Care 46:217–223, 2008
 
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
 
Corrigan PW, Watson AC: The paradox of self-stigma and mental illness. Clinical Psychology: Science and Practice 9:35–53, 2002
 
Britt TW: The stigma of psychological problems in a work environment: evidence from the screening of service members returning from Bosnia. Journal of Applied Social Psychology 30:1599–1618, 2000
 
Greene-Shortridge TM, Britt TW, Castro CA: The stigma of mental health problems in the military. Military Medicine 172:157–161, 2007
 
Britt TW, Greene-Shortridge TM, Brink S, et al: Perceived stigma and barriers to care for psychological treatment: implications for reactions to stressors in different contexts. Journal of Social and Clinical Psychology 27:317–335, 2008
 
Thomas JL, Wilk JE, Riviere LA, et al: The 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, in press
 
Operation Iraqi Freedom 07-09, MHAT-VI Report. Washington, DC, US Office of the Surgeon General, US Army Medical Command, May 2009. Available at www.armymedicine.army.mil/reports/mhat/mhat_vi/MHAT_VI-OIF_Redacted.pdf
 
Spitzer RL, Kroenke K, Williams JBW: Validation and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study. JAMA 282:1737–1744, 1999
 
Cabrera OA, Hoge CW, Bliese PD, et al: Childhood adversity and combat as predictors of depression and post-traumatic stress in deployed troops. American Journal of Preventive Medicine 33:77–82, 2007
 
Depression Management Toolkit. MacArthur Initiative on Depression and Primary Care. Available at www.depression-primarycare.org/clinicians/toolkits
 
Blanchard EB, Jones-Alexander J, Buckley TC, et al: Psychometric properties of the PTSD Checklist (PCL). Behaviour Research and Therapy 34:669–673, 1996
 
Weathers FW, Litz BT, Herman DS, et al: The PTSD Checklist—Civilian Version (PCL-C). Boston, National Center for PTSD, 1993
 
Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 2000
 
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
 
Killgore DS, Cotting DI, Thomas JL, et al: Post-combat invincibility: violent combat experiences are associated with increased risk-taking propensity following deployment. Journal of Psychiatric Research 42:1112–1121, 2008
 
SPSS, Version 16. Chicago, SPSS, 2007
 
Bliese PD, Wright KM, Adler AB, et al: Post-deployment Psychological Screening: Interpreting DD2900. Heidelberg, Germany, US Army Medical Research Unit-Europe, 2005
 
Langston V, Gould M, Greenberg N: Culture: what is its effect on stress in the military? Military Medicine 172:931–935, 2007
 
Andrews G, Issakidis C, Carter G: Shortfall in mental health service utilisation. British Journal of Psychiatry 179:417–425, 2001
 
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
 
Table 1  Demographic characteristics of active duty and National Guard soldiers surveyed after their first deployment to Iraq
Table 2  Rates of mental problems among active duty and National Guard soldiers
Table 3  Stigma among active duty and National Guard soldiers with any mental problem
Table 4  Utilization of mental health care within the past month among active duty and National Guard soldiers reporting any mental problems
Table 1  Demographic characteristics of active duty and National Guard soldiers surveyed after their first deployment to Iraq
Table 2  Rates of mental problems among active duty and National Guard soldiers
Table 3  Stigma among active duty and National Guard soldiers with any mental problem
Table 4  Utilization of mental health care within the past month among active duty and National Guard soldiers reporting any mental problems
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References

Hoge CW, Castro CA, Messer SM, et al: Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351:13–22, 2004
 
Bliese, PD, Wright KM, Adler BA, et al: Timing of postcombat mental health assessments. Psychological Services 4:141–148, 2007
 
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
 
Fikretoglu D, Guay S, Pedlar D, et al: Twelve month use of mental health services in a nationally representative, active military sample. Medical Care 46:217–223, 2008
 
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
 
Corrigan PW, Watson AC: The paradox of self-stigma and mental illness. Clinical Psychology: Science and Practice 9:35–53, 2002
 
Britt TW: The stigma of psychological problems in a work environment: evidence from the screening of service members returning from Bosnia. Journal of Applied Social Psychology 30:1599–1618, 2000
 
Greene-Shortridge TM, Britt TW, Castro CA: The stigma of mental health problems in the military. Military Medicine 172:157–161, 2007
 
Britt TW, Greene-Shortridge TM, Brink S, et al: Perceived stigma and barriers to care for psychological treatment: implications for reactions to stressors in different contexts. Journal of Social and Clinical Psychology 27:317–335, 2008
 
Thomas JL, Wilk JE, Riviere LA, et al: The 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, in press
 
Operation Iraqi Freedom 07-09, MHAT-VI Report. Washington, DC, US Office of the Surgeon General, US Army Medical Command, May 2009. Available at www.armymedicine.army.mil/reports/mhat/mhat_vi/MHAT_VI-OIF_Redacted.pdf
 
Spitzer RL, Kroenke K, Williams JBW: Validation and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study. JAMA 282:1737–1744, 1999
 
Cabrera OA, Hoge CW, Bliese PD, et al: Childhood adversity and combat as predictors of depression and post-traumatic stress in deployed troops. American Journal of Preventive Medicine 33:77–82, 2007
 
Depression Management Toolkit. MacArthur Initiative on Depression and Primary Care. Available at www.depression-primarycare.org/clinicians/toolkits
 
Blanchard EB, Jones-Alexander J, Buckley TC, et al: Psychometric properties of the PTSD Checklist (PCL). Behaviour Research and Therapy 34:669–673, 1996
 
Weathers FW, Litz BT, Herman DS, et al: The PTSD Checklist—Civilian Version (PCL-C). Boston, National Center for PTSD, 1993
 
Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 2000
 
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
 
Killgore DS, Cotting DI, Thomas JL, et al: Post-combat invincibility: violent combat experiences are associated with increased risk-taking propensity following deployment. Journal of Psychiatric Research 42:1112–1121, 2008
 
SPSS, Version 16. Chicago, SPSS, 2007
 
Bliese PD, Wright KM, Adler AB, et al: Post-deployment Psychological Screening: Interpreting DD2900. Heidelberg, Germany, US Army Medical Research Unit-Europe, 2005
 
Langston V, Gould M, Greenberg N: Culture: what is its effect on stress in the military? Military Medicine 172:931–935, 2007
 
Andrews G, Issakidis C, Carter G: Shortfall in mental health service utilisation. British Journal of Psychiatry 179:417–425, 2001
 
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
 
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