Stigma and the military: evaluation of a PTSD psychoeducational program

Modifying attitudes to mental health using comedy as a delivery medium

PURPOSE

Beliefs about other people's potential views or reactions may be powerful determinants of mental health help-seeking behaviours. United Kingdom Armed Forces (UK AF) have made considerable efforts to promote appropriate help seeking though it is often suggested that military personnel remain reluctant to seek help. This study evaluated a novel stigma-reduction method, stand-up comedy, in service personnel.

METHOD

Personnel viewed a regular comedy show or a show containing mental health information. Pre, immediately post-show and 3 months later, military stigmatisation, potential discrimination, mental health knowledge, help-seeking and coping behaviour, talking about mental health, current mental health and alcohol use were measured.

RESULTS

Response rates were 81.3 % pre-show, 67.6 % post-show and 18.9 % at follow-up. Inclusion of mental health material did not appear to detract from show satisfaction. Post-show, intervention group (IG) participants reported significantly less stigmatisation and accurately answered mental health-related questions; in the small numbers followed up, neither difference was maintained, however, IG personnel were statistically significantly more likely to discuss mental health and to advise others about mental health; adjusted analyses suggested that this was related to factors other than the show.

CONCLUSION

In UK AF personnel, embedding mental health awareness within a comedy show format had a short-term positive effect upon military stigmatisation regarding mental health. The low rate of follow-up limited our ability to assess whether this effect was durable. If the longevity of change can be adequately assessed and demonstrated in further research, comedy could potentially form a component of a comprehensive stigma-reduction strategy.

Posttraumatic stress disorder and suicide risk among veterans: a literature review

Posttraumatic stress disorder (PTSD) is frequently associated with suicidal ideation and suicide attempts. Suicide is an important cause of death in veterans, and the risk for intentional death continues to be high many years after service. The aim of the present study was to investigate whether there is a relationship between PTSD and suicidal behavior among veterans. We also discussed the risk factors of suicide among war veterans with PTSD. A systematic review was conducted focusing on war-related PTSD and suicidal behavior. A total of 80 articles from peer-reviewed journals were identified, 34 were assessed for eligibility, and 16 were included. Having a history of PTSD is associated with higher rates of morbidity and mortality and increased the risk for suicidal behavior. The association between PTSD and suicidal behavior was confirmed by the presence of other risk factors and high rates of comorbidity. Current suicidal behavior should be adequately assessed in war veterans.

Print media coverage of post-traumatic stress disorder: content analysis of three major Korean newspapers

The print media is still one of major sources for health-related information. To shed light on how the media accurately delivers information for post-traumatic stress disorder (PTSD), we searched the newspaper articles and analyzed their contents for accuracy in the description of symptoms, causes, and treatment of PTSD. The articles featuring PSTD were searched from the very first available to 2010 at on-line search systems of three major Korean newspapers. A total of 123 articles appeared and the first article appeared in 1984. The number of articles steadily increased till the early 2000s but we found the robust increase in the late 2000s. Among the mentioned symptoms of PTSD: re-experience (39%) was most common, followed by avoidance or numbing (28%) and hyperarousal (22%). Of the 29 articles mentioning treatment of PTSD, 13 mentioned psychotherapy only and 11 mentioned both psychotherapy and medication equally. However, the psychotherapies mentioned were non-specific and only five articles mentioned any empirically supported therapies. The number of articles on PTSD in Korean newspapers has continually increased during the last three decades. However, the quality of information on the treatment of PTSD was questionable.

Consumer perspectives on genetic testing for psychiatric disorders: the attitudes of veterans with posttraumatic stress disorder and their families

The perspectives of patients with posttraumatic stress disorder (PTSD) on genetic research have not yet been investigated in the genetics research literature. To provide a basis for research on attitudes toward genetic research in PTSD, we surveyed the U.S. Military Afghanistan/Iraq-era veterans with PTSD and their social support companions to investigate the attitudes and knowledge about genetics and genetic testing. One hundred forty-six veterans (76 with PTSD and 70 without PTSD) participated in this study. Each veteran participant had a corresponding companion (primarily spouses, but also relatives and friends) who they identified as a primary member of their social support network. Participants and companions completed self-report measures on knowledge of genetics and attitudes toward genetic testing for PTSD. Results indicated that, relative to veterans without PTSD, veterans with PTSD had similar levels of genetic knowledge, but less-favorable attitudes toward genetic testing. Differences persisted after controlling for age and genetics knowledge. No differences between companions of those with and without PTSD were observed. Results suggest that the perspective of those with PTSD regarding genetic testing is in need of further investigation, especially if potentially beneficial genetic testing for PTSD is to be utilized in the target population.

A socio-interpersonal perspective on PTSD: the case for environments and interpersonal processes

Post-traumatic stress disorder (PTSD) is a common reaction to traumatic experiences. We propose a socio-interpersonal model of PTSD that complements existing models of post-traumatic memory processes or neurobiological changes. The model adds an interpersonal perspective to explain responses to traumatic stress. The framework draws from lifespan psychology, cultural psychology and research into close relationships and groups. Additionally, clinical knowledge about PTSD is incorporated. This involves knowledge about shame, guilt, estrangement feelings and protective factors, such as social support and forgiveness. Three levels are proposed at which relevant interpersonal processes can be situated and should be adequately researched. First, the individual level comprises social affective states, such as shame, guilt, anger and feelings of revenge. Second, at the close relationship level, social support, negative exchange (ostracism and blaming the victim), disclosure and empathy are proposed as dyadic processes relevant to PTSD research and treatment. Third, the distant social level represents culture and society, in which the collectivistic nature of trauma, perceived injustice, and social acknowledgement are concepts that predict the response trajectories to traumatic stress. Research by the current authors and others is cited in an effort to promote future investigation based on the current model. Methodological implications, such as multi-level data analyses, and clinical implications, such as the need for couple, community or larger-level societal interventions, are both outlined.

KEY PRACTITIONER MESSAGE

The socio-interpersonal model proposes an interpersonal view of the processes that occur in the aftermath of a traumatic experience. At the individual level, the model integrates the social affective phenomena that clinical research identifies in PTSD patients, including shame, guilt, anger, revenge and the urges or reluctance to disclose. At the level of close relationships, there is an emphasis on the role of the individuals' partner, family or social support in the development or maintenance of PTSD and its recovery. At the distant social level, societal and cultural factors, e.g., individualistic versus collectivistic or other human value orientations, are acknowledged as contributing to the severity and course of PTSD. Increasing attention should be given to new approaches of PTSD treatment that refer to an interpersonal view of PTSD, e.g., communication training, PTSD-specific couples' therapy or community programs.

The costs of conflict: meeting the mental health needs of serving personnel and service veterans

Military mental health has, until recently, been a neglected and marginalized area of interest and although both World Wars saw important advances, in peacetime we typically forget lessons learned in earlier conflicts. Since 2003 however, with high intensity war-fighting on two fronts involving the service personnel of many nations, attention has, once again focused on the immediate and long-term emotional and psychological impact of combat. Whilst we know a lot about posttraumatic stress disorder (PTSD), much less attention has been paid to a variety of other equally, if not more salient yet superficially less dramatic problems facing service personnel deployed on operations, but which are much more likely to lead to mental disorder than traumatic events and the 'horrors of war'. This article describes some of these broader yet less tangible and under-researched issues and discusses the provision of services for the burgeoning veteran community. The mental health of service personnel and veterans is politically sensitive and attracts significant public and media interest. Understanding and responding appropriately to the needs of this group should be of concern to all mental health professionals and it has important consequences, not only for affected individuals but, for the public perception of mental health services as a whole.

Mental illness stigma reduction interventions: review of intervention trials

This article reviews the literature evaluating the effectiveness of various stigma reduction interventions related to mental health illnesses. An integrated search of the English language literature from 1998 to May 2008 was done using CINAHL, Medline, PubMed, Scopus, and PsychINFO databases. The results of this review emphasize that experimental clinical trials hold promise for providing evidence-based data that can be used in mental health practice. Educational and contact-based strategies used in various stigma reduction programs resulted in the most durable gains in knowledge as well as positive attitudinal and behavioral changes needed to decrease the stigma associated with mental illness. Special stigma reduction programs are to be planned for adolescent and elderly targets. Future studies have yet to be designed to identify cost-effective stigma reduction programs. Moreover, interventional studies from different cultures are encouraged. Cross-cultural interventions need to be evaluated and modified to ensure providing culturally relevant interventions.

A cluster randomized controlled trial to determine the efficacy of Trauma Risk Management (TRiM) in a military population

Trauma Risk Management is a peer-support program that aims to promote help-seeking in the aftermath of traumatic events. Prior to its implementation, the British military conducted a randomized controlled trial of Trauma Risk Management against standard care in 12 warships; 6 were randomized to use Trauma Risk Management after collecting baseline measurements. Follow up after 12-18 months found no significant change in psychological health or stigma scores in either group; however, the studied vessels only encountered low numbers of critical incidents. Additionally, measurements of organizational functioning were modestly better in the Trauma Risk Management ships. The authors conclude that within organizations using Trauma Risk Management may be beneficial and may, in time, lead to a valuable cultural shift.

Help-seeking and receipt of treatment among UK service personnel

BACKGROUND

For armed forces personnel, data on help-seeking behaviour and receipt of treatment for mental disorders are important for both research and policy.

AIMS

To examine mental healthcare service use and receipt of treatment in a sample of the UK military.

METHOD

Participants were drawn from an existing UK military health cohort. The sample was stratified by reserve status and by participation in the main war-fighting period of the Iraq War. Participants completed a telephone-based structured diagnostic interview comprising the Patient Health Questionnaire and Primary Care Post-Traumatic Stress Disorder Screen (PC-PTSD), and a series of questions about service utilisation and treatment receipt.

RESULTS

Only 23% of those with common mental disorders and still serving in the military were receiving any form of medical professional help. Non-medical sources of help such as chaplains were more widely used. Among regular personnel in receipt of professional help, most were seen in primary care (79%) and the most common treatment was medication or counselling/psychotherapy. Few regular personnel were receiving cognitive-behavioural therapy (CBT). These findings are comparable with those reported for the general population.

CONCLUSIONS

In the UK armed forces, the majority of those with mental disorders are not currently seeking medical help for their symptoms. Further work to understand barriers to care is important and timely given that this is a group at risk of occupational psychiatric injury.

Do stigma and other perceived barriers to mental health care differ across Armed Forces?

OBJECTIVES

Military organizations are keen to address barriers to mental health care yet stigma and barriers to care remain little understood, especially potential cultural differences between Armed Forces. The aim of this study was to compare data collected by the US, UK, Australian, New Zealand and Canadian militaries using Hoge et al.'s perceived stigma and barriers to care measure (Combat duty in Iraq and Afghanistan, mental health problems and barriers to care. New Engl J Med 2004;351:13-22).

DESIGN

Each member country identified data sources that had enquired about Hoge et al.'s perceived stigma and perceived barriers to care items in the re-deployment or immediate post-deployment period. Five relevant statements were included in the study.

SETTING

US, UK Australian, New Zealand and Canadian Armed Forces.

RESULTS

Concerns about stigma and barriers to care tended to be more prominent among personnel who met criteria for a mental health problem. The pattern of reported stigma and barriers to care was similar across the Armed Forces of all five nations.

CONCLUSIONS

Barriers to care continue to be a major issue for service personnel within Western military forces. Although there are policy, procedural and cultural differences between Armed Forces, the nations studied appear to share some similarities in terms of perceived stigma and barriers to psychological care. Further research to understand patterns of reporting and subgroup differences is required.

Patterns and predictors of treatment delay for mental disorders in a nationally representative, active Canadian military sample

BACKGROUND

Although mental disorders constitute a significant public health problem in military populations, little is known about whether military members seek mental health treatment in a timely manner.

OBJECTIVE

The objective of this study was to examine delays in making the initial treatment contact for various mental disorders in a military population.

DESIGN

A cross-sectional analysis was conducted using data from the Canadian Community Health Survey-Canadian Forces Supplement.

SUBJECTS AND MEASURES

Participants (N = 8441) were assessed for mood and anxiety disorders, using the World Health Organization's Composite International Diagnostic Interview. Those meeting criteria for at least 1 disorder in their lifetime were included in the analyses.

RESULTS

:The majority (82%-100%) of military members with a DSM-IV disorder eventually seek treatment. However, there are significant delays in seeking treatment. Median delays for major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder, panic disorder, and social phobia are 3, 3, 7, 8, and 26 years, respectively. For deployment related posttraumatic stress disorder, longer delays are associated with being in an older age cohort, being male, not having comorbid panic disorder, and shorter military service duration. Across all disorders, longer delays are associated with being in an older age cohort, shorter military service duration, and earlier age of onset.

CONCLUSIONS

Failure to initiate treatment in a timely manner is a major mental health service access issue in the military context. Interventions that aim to shorten treatment delays are needed and should target military members most at risk for delaying treatment.

Psychotrauma and effective treatment of post-traumatic stress disorder in soldiers and peacekeepers

Psychotrauma occurs as a result to a traumatic event, which may involve witnessing someone's actual death or personally experiencing serious physical injury, assault, rape and sexual abuse, being held as a hostage, or a threat to physical or psychological integrity. Post-traumatic stress disorder (PTSD) is an anxiety disorder and was defined in the past as railway spine, traumatic war neurosis, stress syndrome, shell shock, battle fatigue, combat fatigue, or post-traumatic stress syndrome (PTSS). If untreated, post-traumatic stress disorder can impair relationships of those affected and strain their families and society. Deployed soldiers are especially at a high risk to be affected by PTSD but often receive inadequate treatment. Reviews to date have focused only on a single type of treatment or groups of soldiers from only one country. The aim of the current review was to evaluate characteristics of therapeutic methods used internationally to treat male soldiers' PTSD after peacekeeping operations in South Eastern Europe and the Gulf wars.

This systematic literature review returned results pertaining to the symptoms, diagnosis, timing and effectiveness of treatment. Sample groups and controls were relatively small and, therefore, the results lack generalizability. Further research is needed to understand the influence and unique psychological requirements of each specific military operation on the internationally deployed soldiers.

The impact of posttraumatic stress disorder on impairment in the UK military at the time of the Iraq war

The aims of this study were to assess: (1) the relationship between PTSD and impairment, (2) whether there is a threshold in the association of PTSD score and impairment, and (3) whether any of the PTSD criteria are more strongly associated with impairment. We studied 10,069 service personnel from a representative sample of the British Armed Forces to assess the effects of the Iraq war. Participants completed the PTSD checklist (PCL), the general health questionnaire-12 (GHQ-12), the alcohol use disorder identification test (AUDIT) and five questions to assess impairment. 78% of those with a PCL-score of 50 or more endorsed at least one impairment item in comparison to 27% of those with a score below 50. The odds ratio (OR) of impairment in the PCL group with a score of 50 or more was 16.7 (95% CI 12.9-21.6). There was an increasing risk of impairment with an increasing category of PCL-score without a noticeable threshold. For each PTSD subscale: intrusiveness, avoidance/numbing and hyper-arousal, divided into four score categories, there was an increased association with impairment, but the association of avoidance/numbing with impairment was the greatest and independent of the other two criteria (OR 7.2 (95% CI 4.8-10.9). Having a good relationship with a partner had minimal effect on the level of association between PTSD and impairment. Functional impairment is a serious problem for those with PTSD. The impairment is not confined to those with the highest PCL-score. Avoidance/numbing is the criterion which makes the greatest independent contribution to impairment.

The mental health of veterans

For the majority service in the Armed Forces is beneficial and, in the main, military veterans have successful lives. However, a minority have a bleaker outlook as a result of on-going ill health and social exclusion. Whilst the media focuses on Post Traumatic Stress Disorder, in reality the most frequent mental health problems for veterans are alcohol problems, depression and anxiety disorders. These difficulties are difficult to manage as veterans, particularly those who are unwell, demonstrate a reticence to seek help for mental health problems. Another issue is that many veterans are now reserve personnel who have been found to be at greater risk of developing mental health problems than their regular counterparts. Steps to improve the knowledge and expertise of primary care services about veteran's mental health issues and increasing the availability of treatment options are important and are underway.