Mental Health Treatment Experiences of U.S. Service Members Previously Deployed to Iraq and Afghanistan

As many as one in five U.S. service members experience postdeployment posttraumatic stress disorder or depression (1). More than half of service members with documented mental health problems forego needed treatment (2). Concerns about the high rates of unmet mental health needs have ignited a range of new programs and policies to improve access to and use of mental health care among service members (3,4).

Expansion of mental health care within primary care settings is seen as a promising approach to reaching service members who might not seek services from specialty care providers (4,5). High levels of stigmatizing attitudes toward mental illness and mental health treatment have been reported by service members (2), which may drive many to obtain treatment from primary care providers because of reluctance to utilize specialty mental health services (5–7). As initiatives to improve access to and use of mental health care are implemented (3,8), a better understanding of the treatment experiences of service members is critical to inform ongoing and future efforts. Little research attention has focused on whether service members are more likely to obtain mental health care in primary care rather than specialty mental health settings or on their treatment experiences across these two settings.

The purpose of this study was to survey a national sample of active-duty U.S. service members in order to examine mental health treatment utilization across primary care and specialty mental health providers, assess associated levels of treatment intensity, and compare the perceived helpfulness of mental health treatment from primary care providers and specialty mental health providers.

Methods

Eligible participants were individuals previously deployed to Operation Enduring Freedom or Operation Iraqi Freedom (OEF/OIF) who were reachable at a U.S. “landline” phone and resided within one of 24 U.S. geographic areas with the largest number of deployed personnel. Using random-digit dialing, we called households in those areas between August 2007 and February 2008. Additional methodological details have been published elsewhere (9).

The sample for this study was restricted to active-duty service members (N=1,659). Characteristics of the previously deployed population were derived from reports from the Contingency Tracking System Deployment File from the Defense Manpower Data Center. Unlike many prior military studies, this study sampled across a broad representation of occupational specialties and deployment characteristics (for example, multiple deployments, time since last deployment, and length of last deployment). Analyses were conducted by using sample weights to match all military personnel previously deployed to OEF/OIF from 2001 to 2007, which resulted in a sample that was representative on the following dimensions: service branch, 42% Army, 23% Navy, 20% Air Force, and 15% Marines; less than 30 years old, 51%; male, 95%; race-ethnicity, 71% white, 18% black, and 9% Hispanic; married, 81%; and enlisted, 84%. RAND Institutional Review Board approval and informed consent were obtained; respondents were informed that this study was being conducted independently from the military and that their survey responses were confidential.

To assess mental health treatment utilization, respondents were asked, “In the past 12 months have you visited any professional like a doctor, psychologist, or a counselor to get help with issues related to stress, emotional, alcohol, drug, or family problems?” Respondents were then asked who they visited for help with these problems: “a regular medical doctor or primary care physician,” “a mental health specialist like a psychiatrist, psychologist, or counselor,” or “other” provider. For each provider seen, respondents were asked about the number of visits in the past 12 months, average length of visits, and whether the provider helped a lot or some, a little, or not at all.

Results

Approximately 17% (N=276) of respondents reported obtaining mental health care in the prior 12 months. As shown in Table 1, about three times as many respondents had sought help from a specialty mental health provider (N=248, 14% weighted) as from a primary care provider (N=79, 5%) (p<.001). Moreover, the intensity of mental health treatment was significantly greater when care was delivered by a specialty provider rather than a primary care provider. On average, respondents who saw specialty mental health providers had 10.3 visits in the past year, averaging 47.6 minutes each. In comparison, respondents who had seen a primary care provider reported an average of 5.3 visits, averaging 38.5 minutes each (difference in visits, p<.001; difference in session length, p<.001).

Specialty mental health providers were rated as significantly more helpful than primary care providers. Of the respondents who had visited specialty mental health providers, 79% reported that treatment helped a lot or some, and no one reported that the treatment had not been at all helpful. In contrast, only 51% of those who had seen primary care providers thought that the treatment had helped a lot or some, and 15% reported that the treatment had not helped at all.

Discussion and conclusions

Contrary to current perceptions (6,10), previously deployed active-duty personnel were much more likely to visit specialty mental health providers than primary care providers. Similar results have been found among Canadian military personnel (11). Our study also indicated that treatment with specialty mental health providers involved more numerous and longer visits than treatment with primary care providers, possibly reflecting the greater availability of certain interventions in specialty mental health settings (for example, psychotherapy) (12). Service members also reported more positive experiences with specialty mental health providers. Every respondent who had seen a specialty provider thought that the treatment had helped to some degree. In contrast, 15% of respondents who had visited primary care providers thought that the treatment had not helped at all.

These findings raise questions about what factors contribute to respondents’ treatment utilization patterns and experiences. One possibility is that service members may prefer the types of interventions that are more widely available from specialty mental health providers (psychotherapy) than from primary care providers (medication). Among service members, one of the most highly endorsed barriers to seeking mental health treatment is concerns about the side effects of medications is one of the most highly endorsed barriers to seeking mental health treatment (9). In this study, 21% (N=31) of the respondents who had been prescribed psychotropic medications felt that medication did not help at all, though they varied by whether they had seen a primary care provider, specialty mental health provider, or other type of provider (data not shown). Among the general U.S. population, psychotherapy is overwhelmingly preferred over medications, and specialty mental providers are perceived as more helpful than general medical providers (12,13). Thus the treatment attitudes and experiences of service members may be more similar to those of the civilian population than expected.

Findings may also reflect aspects of the system of care during the time of the study. For example, postdeployment mental health screening programs may have contributed to specialty mental health referrals (3). Further, efforts were being launched during the study period to enhance access to primary care–based mental health treatment in the military health system (3,14), but these were not yet fully implemented.

It is important to recognize the limitations of this study. Data were collected only from individuals with a land-based telephone who lived in 24 U.S. geographic areas. In addition, respondents’ perceptions of the helpfulness of treatments may not reflect actual quality of services or treatment outcomes. Strengths of this study include its broad representation across service branches, occupational specialties, and deployment characteristics and the fact that it was conducted confidentially and independently from the military.

This study highlights the importance of assessing service members’ treatment experiences across various provider types, interventions, and settings. Further examination is needed of service members’ preferences for and responsiveness to diverse approaches to expanding mental health care in primary care settings, which can vary from embedding specialty mental health providers in primary care settings to employing care managers to coordinate treatment between primary care and specialty mental health providers (15). As major policies are developed to best address the unmet mental health needs of service members, it is critical that the process is guided by data on patterns of treatment utilization and preferences.