Barriers to Engaging Service Members in Mental Health Care Within the U.S. Military Health System

There is growing recognition of the mental health consequences associated with deployment and service among military service personnel (1). Several studies document the prevalence of mental health problems in the military (2–5) and highlight the potential barriers that members of the military may face in accessing mental health services (6–8). As the primary source of health care for service members, the military health system (MHS) bears special responsibility in addressing these issues. With 9.6 million beneficiaries, 56 medical centers, and 360 ambulatory care clinics, the MHS represents one of the largest health systems in the United States.

Primary care has been referred to as the de facto mental health system (9–11). Over the past two decades, multiple efforts have been implemented in health systems to integrate behavioral health into primary care settings. Often referred to as “collaborative care,” the goal of these initiatives is to integrate and improve the mental health services that are delivered in primary care. Common components of these models include efforts to prepare the practice setting by training providers in behavioral health issues; use of a team approach, most often involving a care manager for engaging patients, improving their adherence to treatment, and assessing treatment response; and use of strategies to enhance the interface between specialists and primary care (12).

In the MHS, service members have an average of three encounters per year in primary care (13). There have been several attempts to integrate behavioral health services into primary care settings and line units in the MHS. In 2007, the Army began integrating mental health services into all of its primary care clinics, including the colocation of mental health specialists and the use of nurse care managers (14,15). In 2013, it expanded the assignment of trained behavioral health clinicians to line units and troop medical clinics. These efforts were intended to expand access to behavioral health specialty providers and reduce soldier concerns with seeking help. Despite these efforts, concerns about access to and quality of mental health treatment within the MHS persist (1,16).

This qualitative study was designed to understand stakeholder experiences regarding treatment of posttraumatic stress disorder (PTSD) and depression in Army primary care clinics (17). Specifically, we gathered information about participants’ experiences with barriers to accessing and utilizing mental health care within the U.S. Army. In addition to gathering insights regarding obstacles and barriers, we asked stakeholders for recommendations to increase help seeking among soldiers with mental health problems.

Methods

We conducted a series of one-on-one interviews with stakeholders within the context of a large randomized controlled trial testing the effectiveness of a centrally assisted, stepped-care model of collaborative care for PTSD and depression. The model was compared with the standard version of collaborative care offered throughout the MHS. The study was conducted across six large military installations from which service members deployed and to which they returned; together these installations housed 18 primary care clinics (17). Stakeholder groups included patients of the primary care clinics who were recruited for the study, care providers in clinics at each installation, and care managers implementing the study intervention. Patient participants were drawn from both intervention arms in the study. Procedures were approved by all relevant institutional review boards. All stakeholders who were interviewed provided oral consent for participation.

Patients

We randomly selected patients within each site to participate in up to three 30-minute interviews. We randomly drew patients’ names and contact information on a rolling basis across the one-year study enrollment period. At each site, we attempted to recruit six patients, two from each of the intervention conditions, for a total of 36 patients across the study. After sending an introductory e-mail, we contacted patients by phone to ascertain willingness to participate and schedule an interview. Of the 60 soldiers invited to participate, we were unable to reach 14, three declined participation, and five were no-shows.

Once recruited, each patient was asked to participate in up to three interviews across the one-year time span. Each of the three interviews followed the same protocol in an attempt to assess how experiences and responses evolved over time. Interviews were scheduled to occur at three time points: within approximately one to two months, four to five months, and seven to eight months of the soldier’s entrance into the study. For some patients, delays in scheduling interviews increased the interval between appointments.

All interviews were conducted over the phone by trained qualitative interviewers assisted by a notetaker. Using a semistructured interview guide, the interviewer asked about expectations regarding study participation; experiences getting care and working with their assigned care manager; use of mental health services, including barriers to or facilitators of mental health services that they experienced personally; and use of study tools and resources, for example, Web-based self-management resources, and recommendations for improving the delivery of mental health care to soldiers with PTSD or depression. Interviews were recorded and transcribed, and they lasted less than 30 minutes. Once transcripts were verified, recordings were deleted. Patients received a $25 gift card following each interview, for a potential total remuneration of $75 for participating in all three interviews.

Providers

Given the absence of centralized rosters of providers, the study site coordinators generated lists of all health care providers working within the installations’ clinics, by setting and specialty type. From these lists, the qualitative study team recruited a similar number of general medicine providers (physicians, physician assistants, and nurse practitioners) and mental health specialty providers (psychiatrists, psychologists, and social workers). For the mental health providers, we sought providers working in the primary care clinic as well as the behavioral health clinics and operational units on the installation, given that patients in the study could be receiving care in these locations as well, and they could be interacting with the care manager. The study team randomly recruited five providers per site from the lists of providers until it reached its target of 30 providers. The study team contacted 100 providers across the six sites, and interviewed 31. Providers were asked to participate in one 15- to 30-minute interview about their experiences addressing soldiers’ mental health needs; delivering behavioral health care within the MHS, including barriers to or challenges in treating soldiers with PTSD or depression in their clinic; and any specific experience related to the study. At the end of each interview, providers were asked if they had any additional thoughts they wanted to share about addressing the mental health needs of soldiers. Participating providers were given a $35 gift card for participating.

Care Managers

The seven study care managers (licensed nurses responsible for managing care of specific patients) included six who were located at a specific site and one who was centrally located and provided backup or overflow care management; six of the seven were female. They were asked to participate in two one-hour interviews about their experiences with study patients and providers. The timing of interviews was based on the study’s life cycle: one took place in the first three months of the site’s study enrollment period and one occurred in the last month of the study. The early and late interview discussion guide covered a range of topics, including experiences engaging patients into care (for example, working with the patient to set treatment goals and schedule appointments), including any barriers they have encountered in delivering services, sharing information with providers both on- and off-site, and perceptions of the specific study tools and resources they were provided—and any other comments they might have about addressing soldiers’ mental health needs. During the final interview, we also used a medical record–assisted recall approach to foster feedback on their experiences with five specific patients whose care they managed. For the assisted-recall methods, we randomly chose patients who participated in the intervention at each site, and their names were provided to the care manager at the time of the interview. All interviews were recorded and transcribed. Once transcripts were verified, recordings were deleted. Care managers were offered a $75 gift card for participating.

Analysis

All transcripts were coded by using ATLAS.ti qualitative data analysis software. A coding scheme was drafted, used to code five transcripts, checked by the analytic team, and refined and expanded. To ensure interrater reliability, another member of the team reviewed a random selection of each set of transcripts to ensure consistent application of theme categorizations. Review of interview transcripts of the same participants across their three interviews suggested that patients did not perceive changes in barriers to treatment over time but rather gradually became more engaged in care.

Results

A total of 76 stakeholders (38 patients, 31 providers, and seven study care managers) were interviewed between July 2012 and June 2014 about their experiences with receiving or delivering mental health care within the MHS. Table 1 displays demographic characteristics of the 38 patients who participated in the initial interviews; 31 (82%) completed at least two interviews, and 27 (71%) completed all three. Table 2 displays information about the 31 providers who were interviewed.

During these discussions, 99% (N=75) of stakeholders discussed a number of issues that they perceived as inhibiting timely access to and receipt of high-quality mental health care. Issues raised across stakeholder groups fell into two main categories: structural factors associated with the system itself and institutional attitudes and cultural issues across the U.S. military.

Structural Issues

Timely receipt of mental health care is dependent not only on identifying the need for care and reaching out for help but also on whether care is available where and when it is needed. When asked about the types of challenges that got in the way of getting help or delivering services to soldiers with mental health problems, 47% (N=36) of stakeholders raised issues about the structure of the military health care system as potential barriers to delivering care. These issues included concerns about the capacity of the system, for example whether there were enough providers available to meet patients’ needs (noted by 15 [20%] stakeholders). Both patients and providers raised this issue, particularly with respect to ensuring timely access to appointments. Table 3 contains illustrative quotes of stakeholder perceptions of structural barriers to care.

A second structural concern included constraints on clinic hours and scheduling practices. Thirty-nine percent (N=12) of providers and 57% (N=4) of care managers spoke of the limited time available during each visit to tend to the patient’s full range of concerns. At the same time, many providers (particularly those engaged in trying to do follow-up telephone care) and care managers mentioned concerns about the overlap between their work hours and those of their patients, which made it nearly impossible to reach patients by phone during the day. In the MHS, care is such that appointments are offered only during duty hours, requiring that service members obtain permission from their supervisors or commanders to be absent from work in order to attend the appointment. As a result, their health care is subject to the varying knowledge, attitudes, beliefs, and will of their commanders, a subject that also arises below in the discussion of institutional attitudes and culture. Indeed, 32% (N=12) of patients reported inability to take time off as a barrier to care.

Institutional Attitudes and Culture

The attitudes and culture of the Army as an institution and workplace setting were among the issues identified as affecting access to care. The military ethos values “toughing it out” and espouses that persons with problems are weak. These attitudes, sometimes defined as “public stigma,” are perceived to be a major impediment to care seeking among military personnel. Stakeholders commonly cited these issues when asked about barriers to care that they had experienced. These issues broadly fell into two main areas: attitudes and perceptions of the unit (or line) leadership toward soldiers who seek mental health care and the possibility of negative career repercussions for persons who access care. Thirty-nine percent (N=15) of patients, 10% (N=3) of providers, and 86% (N=6) of care managers voiced concerns about attitudes among leaders and their willingness to allow soldiers to schedule appointments. Indeed, 39% (N=15) of patients were concerned that requesting time off for mental health visits and attending such visits would have an adverse impact on their careers, either through fewer promotion opportunities or even separation from the military. Table 4 summarizes stakeholder perceptions of institutional barriers to treatment that were related to attitudes and culture.

Recommendations for Improving Access and Receipt of Care

During each interview, we asked for suggestions on how to improve access to mental health care for soldiers. All patients, all care facilitators, and one-quarter of providers offered at least one suggestion. Among the 52 stakeholders who made a recommendation, 75% (N=39) called for expanding access for soldiers and their families to resources available off the installation. Soldiers mentioned not only that community resources were available but also that such resources were often preferred because they were perceived to offer a greater likelihood of confidentiality and because they were available outside work hours. Other suggestions included addressing the attitudes of leadership directly through targeted training programs—25% (N=13) of stakeholders commented that military leaders needed to become more aware of mental health challenges and issues facing soldiers and to be taught how to be more empathic and to facilitate soldiers’ receipt of care. Others mentioned a need to encourage providers to communicate directly with command when there was a lack of support for service members in keeping their appointments. Table 5 lists recommendations for encouraging help seeking.

Discussion

Ensuring access to mental health services for U.S. service members has been the focus of several national efforts, including a presidential executive order (18). The Department of Defense and each of the military services have implemented many programs designed to raise awareness about the mental health issues associated with deployment, promote help seeking, and expand workforce capacity to meet demand for mental health services (19). Our findings reveal that despite these efforts, many stakeholders still perceive and experience significant barriers to care. Our study found significant overlap among patients seeking access to mental health care within the Army medical system and those responsible for providing or facilitating such care with respect to the obstacles and challenges faced by soldiers when trying to get help for mental health concerns.

Prior studies of barriers to mental health care among civilian populations often identify concerns about affordability and effectiveness of care (8). Many studies have suggested that the greatest barrier to receiving and remaining in care for military personnel was related to stigma among soldiers (5,8,20,21), and we found evidence of this issue among all of our stakeholders. However, even more frequently, stakeholders raised concerns about structural aspects of the Army medical system as well as about the institutional culture of the Army (8). Structural issues may be easier to change than cultural attitudes, yet they persist in spite of many efforts to facilitate access to mental health services and support (19). All of the service members in our study had a mental health problem and were assigned to a care manager to help them navigate care and obtain needed appointments. Yet these stakeholders noted significant structural and organizational barriers to securing timely care.

Both patients and providers perceived a shortage of professionals and expressed frustration over the resulting long wait times for appointments. Providers also noted that the short visit times limited their ability to attend to all of the patient’s concerns, including those related to mental health. Addressing these concerns will involve considering structural changes to improve the systems of mental health service delivery, such as hiring more mental health providers, expanding access to off-post mental health providers, lengthening the time allotted for primary care sessions, and expanding clinic hours to offer appointments during evenings and weekends.

Both patients and providers also noted that attitudes among Army leaders toward help seeking, particularly attitudes that discourage getting help and promote the “tough it out” ethos, were a significant barrier for soldiers who needed or wanted help. A handful of other studies have also documented the influence of poor leadership not only on the experience of postdeployment mental health problems (22) but also on stigma and soldier help seeking (5,8,20,21). Britt and others (23) found that leaders who engaged in negative behaviors, such as embarrassing unit members in front of others, were more likely to create work environments conducive to higher levels of stigma concerning mental health care among their soldiers. Our stakeholders reported that getting approval to leave work and attend appointments may be intimidating, and many feared that there could be adverse career repercussions if they did so. Britt and colleagues (23) also observed that leaders who engaged in more positive behaviors were more likely to make accommodations for individuals who sought treatment. In a 2013 study of active duty soldiers, Zinzow and colleagues (8) noted that leadership attitudes and behaviors were critical as both potential barriers to and facilitators of treatment seeking.

Taken together, these findings suggest that improving military leaders’ attitudes about mental health may be important for facilitating help seeking. Given the multiple levels of leadership within the military, these efforts need to include senior, mid-grade, and junior officers to ensure that they reach all of the microcultures within the overall military command climate. Within the first-responder community, other agencies have implemented Psychological First Aid for Leaders to change how leaders understand and respond to individuals who experience mental health issues (www.phe.gov/abc). This course may serve as a model for the Department of Defense as it continues to address barriers to mental health treatment among service members and promote more supportive work environments.

A few study limitations should be noted. Specifically, our data were collected from patients who had successfully overcome some of the barriers and who sought care at relatively large installations with robust care systems. As such, their concerns may underrepresent the magnitude and scope of barriers facing service members in other settings, including those at smaller military installations. Furthermore, these data were collected from within Army clinics, and it is unclear to what extent the same issues would be identified among patients in clinics managed by other service branches. However, we expect that regulatory tensions between the military unit and persons seeking military medical care are likely to remain qualitatively similar across branches of service. Finally, few study participants sought care outside the MHS and, therefore, did not discuss barriers they might face in the civilian service sector. There has also been a proliferation of civilian provider networks that serve service members, veterans, and their families. As such, whether service members face similar barriers within those systems has yet to be evaluated.

Conclusions

Military service, particularly during a period of active combat, is arguably one of the most stressful occupations. Given added concerns about trauma exposures, both before and after service and deployment, there is sound basis to enhance access to mental health services for service members. The issues and concerns regarding the role of the leadership and commanders in influencing service members’ willingness and ability to seek such care are of significant concern. Commanders are often regarded as members of the care team, and they have unusual access to medical records (24). These factors suggest a need to reexamine commanders’ roles around mental health service delivery and to ensure that they are facilitators of and not barriers to the mental health care needed by their troops.