Perceived stigma and barriers to care in UK Armed Forces personnel and veterans with and without probable mental disorders

Barriers to Mental Health Care in US Military Veterans

BACKGROUND

Military veterans often encounter multiple obstacles to mental health care, such as stigma, practical barriers (e.g., high cost), and negative beliefs about mental health care. To date, however, nationally representative data on the prevalence and key correlates of these barriers to care are lacking. Such data are critical to informing population-based efforts to reduce barriers and promote engagement in mental health treatment in this population.

METHODS

Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed 4,069 US veterans, 531 (weighted 15.0%) of whom screened positive for a mental disorder but never received mental health treatment. Multivariable logistic regression and relative importance analyses were conducted to identify key predisposing, enabling, and need-based factors associated with endorsement of stigma, instrumental barriers, and negative beliefs about mental health care.

RESULTS

A total 47.1% of veterans endorsed any barrier to care, with 38.7% endorsing instrumental barriers to care, 28.8% perceived stigma, and 22.0% negative beliefs about mental health care. Lower purpose in life, grit, and received social support were most consistently associated with these barriers to care.

CONCLUSIONS

Nearly half of US veterans with psychiatric need and no history of mental health treatment report barriers to care. Modifiable characteristics such as a low purpose in life, grit, and received support were associated with endorsement of these barriers. Results may help inform resource allocation, as well as prevention, psychoeducation, and treatment efforts to help reduce barriers and promote engagement with mental health services in this population.

Shorter communications: Exploring the impact of a brief smartphone-based alcohol intervention app (DrinksRation) on the quality of life of UK military veterans

Alcohol misuse - defined as consuming more than 14 units of alcohol per week - is a well-established problem among veterans. This study investigated the change in quality of life among help-seeking UK veterans who completed a 28-day brief alcohol intervention delivered via a digital smartphone application (called DrinksRation) and have previously sought clinical help for a mental health disorder. This study was a secondary outcome analysis of data collected during a randomised control trial. In total, 123 UK veterans participated in the study and were randomly allocated to either the intervention or control arm. Participants completed self-report questionnaires regarding their alcohol use and quality of life (WHOQOL-BREF) at baseline, day 28 (end of intervention), day 84, and day 168. At the primary endpoint (day 84), we found significantly greater improvements in the intervention arm compared to the control arm for psychological quality of life (Cohen's d = 0.47), and environmental quality of life (d = 0.34). However, we observed no statistically significant differences between the intervention and control arm for social relationships and physical quality of life. Further, for day 168 we found no significant differences. Findings suggest that DrinksRation can increase quality of life among help-seeking veterans who have previously sought help for a mental health disorder, but the increases were modest and restricted to certain domains. Additional treatment may be needed for long-term and sustained improvements in quality of life.

Gender differences in structural and attitudinal barriers to mental healthcare in UK Armed Forces personnel and veterans with self-reported mental health problems

PURPOSE

Structural and attitudinal barriers often hinder treatment-seeking for mental health problems among members of the Armed Forces. However, little is known about potential gender differences in structural and attitudinal barriers among members of the UK Armed Forces. The current study aimed to explore how men and women differ in terms of these barriers to care among a sample of UK Armed Forces personnel and veterans with self-reported mental health problems.

METHODS

Currently serving and ex-serving members of the UK Armed Forces who self-reported a mental health problem were invited to participate in a semi-structured phone interview on mental health and treatment-seeking. The final sample included 1448 participants (1229 men and 219 women). All participants reported on their current mental health, public stigma, self-stigma, and barriers to mental healthcare.

RESULTS

Overall, men and women reported similar levels of both structural and attitudinal barriers, with no significant differences detected. The highest scores for both men and women were observed in attitudinal barriers relating to self-stigma domains, which encapsulate internalised attitudes and beliefs about mental illness and treatment.

CONCLUSIONS

Findings suggest that anti-stigma campaigns can be targeted simultaneously at both men and women within the Armed Forces. In particular, targeting self-stigma may be beneficial for health promotion campaigns.

Barriers and facilitators to mental healthcare for women veterans: a scoping review

BACKGROUND

Traditionally, veteran research and support have centred on the requirements of a predominantly male population. However, as female participation in the Armed Forces increases and their roles diversify, consideration of women's unique mental health needs is imperative. Women veterans are at greater risk of post-service mental health challenges than their male counterparts, and female mental health outcomes have deteriorated in recent years.

AIMS

To determine the provenance of these outcomes, a scoping review considering both barriers and facilitators to female veteran participation in mental health services was conducted.

METHODS

A review was carried out following the 2020 Joanna Briggs Institute Scoping Review framework. Twenty-four papers were identified, with all but one originating from the US.

RESULTS

This research indicated that whilst women experience barriers common to male veterans (e.g. help-seeking stigma), they also experience unique gender-specific barriers to accessing mental healthcare services (e.g. lack of gender-sensitive treatment options, feeling uncomfortable) and such barriers result in under-utilization of services.

CONCLUSIONS

Literature indicates that consideration and mitigation of these barriers might improve access and health outcomes for women veterans. Further research is required outside the US to understand the barriers to mental healthcare experienced by women veterans internationally.

'You get looked at like you're failing': A reflexive thematic analysis of experiences of mental health and wellbeing support for NHS staff

Staff in the National Health Service (NHS) are under considerable strain, exacerbated by the COVID-19 pandemic; whilst NHS Trusts provide a variety of health and wellbeing support services, there has been little research investigating staff perceptions of these services. We interviewed 48 healthcare workers from 18 NHS Trusts in England about their experiences of workplace health and wellbeing support during the pandemic. Reflexive thematic analysis identified that perceived stigma around help-seeking, and staffing shortages due to wider socio-political contexts such as austerity, were barriers to using support services. Visible, caring leadership at all levels (CEO to line managers), peer support, easily accessible services, and clear communication about support offers were enablers. Our evidence suggests Trusts should have active strategies to improve help-seeking, such as manager training and peer support facilitated by building in time for this during working hours, but this will require long-term strategic planning to address workforce shortages.

Moral Injury and Recovery in Uniformed Professionals: Lessons From Conversations Among International Students and Experts

Introduction

In the course of service, military members, leaders, and uniformed professionals are at risk of exposure to potentially morally injurious events (PMIEs). Serious mental health consequences including Moral Injury (MI) and Post-traumatic stress disorder (PTSD) can result. Guilt, shame, spiritual/existential conflict, and loss of trust are described as core symptoms of MI. These can overlap with anxiety, anger, re-experiencing, self-harm, and social problems commonly seen in PTSD. The experiences of General (retired) Romeo Dallaire and other international experts who have led in times of crisis can help us better understand MI and recovery.

Objectives

In honor of Dallaire, online opportunities were created for international students and leaders/experts to discuss topics of MI, stigma, and moral codes in times of adversity as well as the moral impact of war. We aimed to (1) better understand MI and moral dilemmas, and (2) identify key insights that could inform prevention of and recovery from MI.

Materials and Methods

Webinars and conversations of 75-90 min duration on MI and recovery were facilitated by Leiden University, the University of Alberta and the Dallaire Institute for Children, Peace and Security between General Dallaire, world experts, and graduate students. Sessions were recorded, transcribed and thematically analyzed with NVivo using standard qualitative methodology.

Results

Ninety four participants engaged in conversations. Student engagements were attended by participants [N = 51; female (29), male (22)] from the Netherlands and Canada. Conversations were held with international experts [N = 43; female (19) and male (24)] from North America, Europe, Australia and the global south. Themes included: (1) recognizing the impact of exposure to PMIEs, (2) reducing stigma around MI, and (3) embracing the spiritual depth of humanity.

Conclusion

Exposure to PMIEs can have devastating impacts on military members, leaders and other uniformed professionals. This may lead to development of MI and PTSD. Recognizing MI as honorable may reduce stigma and psychological harm, and facilitate help-seeking among uniformed personnel and other trauma-affected populations. Salient efforts to address MI must include use of accurate measurements of MI and integrated holistic therapeutic approaches, inclusive of spiritual and social components. Urgency remains regarding the prediction, identification and treatment of MI.

Posttraumatic Stress Responses and Psychological Well-being in Norwegian Medical Helicopter Personnel

OBJECTIVE

Emergency medical personnel are exposed to multiple stressors, including those of psychological etiologies. The aim of this study was to report the prevalence of anxiety, depression, and posttraumatic stress symptoms in Norwegian medical helicopter personnel and to determine to what degree they report personal growth or deprecation due to exposure to work-related events.

METHODS

This was a web-based, cross-sectional survey performed among rescue paramedics and physicians staffing helicopter emergency medical services and search and rescue helicopters between May 5, 2021, and July 5, 2021. Questions included demographic data, the traumatic events exposure index, the Generalized Anxiety Disorder 7 scale, the Patient Health Questionnaire 9 (Depression), the posttraumatic change scale, and the posttraumatic symptom scale.

RESULTS

Of the 245 eligible participants, 10 declined to take part and 74 failed to answer, producing a response rate of 66% (72 rescue paramedics and 89 physicians). Of the study population, 3.9 % reported manifest posttraumatic stress disorder symptoms, and 1.9% described moderate to severe depression and anxiety. The majority (76%) described posttraumatic emotional growth because of their work experience.

CONCLUSION

Despite exposure to several traumatic stressors, participants reported a lower prevalence of posttraumatic stress symptoms, depression, and anxiety compared with a Norwegian adult population.

Gambling problems and help-seeking in serving United Kingdom military personnel: A qualitative study

INTRODUCTION

In military personnel are vulnerable to gambling problems, yet many are reluctant to seek help. The aim of the current study was to explore the lived experience of problem gambling and help-seeking among serving members of the United Kingdom Armed Forces.

METHODS

Seventeen individuals from a larger, cross-sectional survey of gambling and wellbeing in the Royal Air Force (RAF) completed semi-structured interviews. Interview questions focused on personal experiences, the context of the RAF and its influence, knowledge and experiences of treatment and support services, and the impact of COVID-19.

RESULTS

Reflexive thematic analysis revealed four themes: (1) harmful and protective occupational factors; (2) socio-cultural and personal influences; (3) organizational attitudes toward mental health and help-seeking, and (4) current support pathways and provision.

DISCUSSION

Findings also indicated that gambling and alcohol use are common within the RAF, and that personnel are actively coping with mental health challenges.

Pregnancy and posttraumatic stress disorder: associations with infant outcomes and prenatal care utilization

BACKGROUND

Posttraumatic stress disorder (PTSD) affects 3.6-9.7% of women, and has been associated with adverse outcomes in pregnancy; however, associations with prenatal care (PNC) utilization are not clear.

OBJECTIVE

To evaluate associations of PTSD in pregnancy with PNC utilization and adverse infant outcomes in an active-duty military population (a population with universal health insurance).

METHODS

This was a retrospective cohort study of pregnant active-duty service members in Department of Defense Birth and Infant Health Research program data from 2007 to 2014. Administrative medical encounter data were used to define PTSD cases and outcomes of interest. Descriptive statistics and multivariable log-binomial regression compared PNC utilization and adverse infant outcomes (preterm birth, small for gestational age [SGA], major birth defects) among service members with current PTSD (defined as PTSD in the year prior to pregnancy or during pregnancy) to those without current PTSD.

RESULTS

Of the 103,221 singleton live births identified, 1657 (1.6%) were born to active-duty service members diagnosed with current PTSD. Service members with PTSD were more likely to initiate PNC in the first trimester (93.5% vs. 90.2%) and score adequate plus on the Adequacy of Prenatal Care Utilization Index (63.2% vs. 40.0%) compared to service members without PTSD. PTSD case status was not associated with preterm birth, SGA, or major birth defects, regardless of the adjustment set used (fully adjusted RR 0.96, 95% CI 0.82-1.13; RR 1.08, 95% CI 0.79-1.48; and RR 1.03, 95% CI 0.79-1.34, respectively).

CONCLUSION

For pregnant service members with current PTSD, no associations with adverse infant outcomes were noted, and these patients initiated care earlier and had higher PNC utilization scores compared to pregnant service members without current PTSD. Universal health care coverage and utilization of PNC in this population may mitigate adverse pregnancy outcomes observed in civilian populations of patients with PTSD.

A Service Evaluation of the Military HeadFIT Initiative: An Implementation Study

(1) Background: UK Armed Forces personnel provide first response, support and protection during national and international disasters and conflicts. They thus have a psychologically challenging role which requires them to maintain a good state of mental health and wellbeing. HeadFIT is a preventative initiative developed to help foster mental fitness through various self-help tools and resources online including techniques to de-stress and increase drive. This paper reports on an independent service evaluation of HeadFIT to examine feasibility and acceptability among Ministry of Defence (MOD) personnel. (2) Methods: Qualitative interviews were held with the HeadFIT beneficiaries, including military personnel and civil servants. The beneficiaries provided feedback on HeadFIT through questionnaires and interviews, and website traffic data were also collected. Qualitative data were analysed using framework analysis. (3) Results: Beneficiaries generally reported positive views on the HeadFIT initiative, with most agreeing that the tools could support them to foster their mental fitness. However, concerns were raised around the uptake of HeadFIT and participants suggested methods to improve usability. (4) Conclusions: Several recommendations were made to improve the resources, usability, uptake, and implementation and communication of HeadFIT.

Gender differences in barriers to mental healthcare for UK military veterans: a preliminary investigation

INTRODUCTION

Limited UK research focuses on female military veterans' gender-related experiences and issues when accessing civilian mental healthcare support. This study sought to illuminate a preliminary understanding of any gender differences in barriers that may discourage them accessing mental healthcare support.

METHODS

A total of 100 participants completed an open online survey of UK triservice veterans who identified as having experienced postmilitary mental health problems. They completed a 30-item Barriers to Access to Care Evaluation scale and were asked to elaborate using free-text questions. Resulting quantitative data were analysed for gender-related differences, while the qualitative text was thematically explored.

RESULTS

While stigma, previous poor experience of mental healthcare and a lack of trust in civilian providers were found to act as barriers to postmilitary support for both men and women, significantly more women reported that their gender had also impacted on their intention to seek help. Women also commented on the impact of gender-related discrimination during service on their help-seeking experiences.

CONCLUSIONS

While efforts are being made by the UK Ministry of Defence to reduce barriers to mental healthcare for those still serving in the Armed Forces, it has been more difficult to provide a similar level of support to the veteran population. With little veteran research focusing on the specific experiences of women, this study suggests that female veterans encounter specific access barriers and issues related to their gender. Further research is therefore needed to ensure these findings are addressed.

Family and occupational functioning following military trauma exposure and moral injury

INTRODUCTION

Evidence is growing regarding the impact of potentially morally injurious events (PMIEs) on mental health; yet how moral injury may affect an individual's occupational and familial functioning remains poorly understood.

METHOD

Thirty male veterans who reported exposure to either traumatic or morally injurious events and 15 clinicians were recruited for semi-structured qualitative interviews.

RESULTS

While many veterans experienced psychological distress postevent, those who experienced PMIEs especially reported social withdrawal and engagement in aggressive, risk-taking behaviours. This was highly distressing for family members and created a tense, volatile home and workplace environment that was difficult for others to navigate. Following PMIEs, employment could be used as a cognitive avoidance strategy or as a means to atone for transgressive acts. In cases of moral injury, clinicians considered that targeted support for spouses and accessible guidance to help children to better understand how their military parent may be feeling would be beneficial.

CONCLUSIONS

This study provides some of the first evidence of the pervasive negative impact of PMIEs on veterans' familial and occupational functioning. These findings highlight the need to comprehensively screen for the impact of moral injury on daily functioning in future studies that goes beyond just an assessment of psychological symptoms.

The mediating role of resilience on psychopathology following childhood adversities among UK armed forces veterans residing in Northern Ireland

BACKGROUND

Childhood adversities can have a deleterious impact on mental health. Elevated levels of such adversities have been reported in veteran populations. Levels of resilience may be protective but early adverse experiences may impact on the development of resilience in the first instance.

OBJECTIVE

This study aims to identify classes of childhood adversities among UK military veterans residing in Northern Ireland (NI) and explore levels of resilience and the mediating role resilience may play following such experiences in relation to mental health.

METHOD

The study utilizes data from the Northern Ireland Veterans' Health and Wellbeing Study (n = 656). All participants were UK Armed Forces veterans who were residents of NI with an average age of 56 (586 males, 70 females).

RESULTS

Four childhood adversity classes were revealed, with almost a half of the sample experiencing early adverse experiences. Individuals who experienced a range of adversities, particularly those related to maltreatment were more likely to have PSTD, depression and anxiety disorders and lower levels of resilience. However, those who experienced adversity related to family dysfunction had similar levels of resilience as the low risk class, suggesting tentatively that some adversity may be protective. Mediation analyses revealed that veterans with elevated levels of resilience were less likely to have psychological problems following negative childhood experiences.

CONCLUSIONS

The study highlights the importance of promoting resilience building programmes among military veterans, especially among those who experienced maltreatment as a child.

Social stigma is an underestimated contributing factor to unemployment in people with mental illness or mental health issues: position paper and future directions

Background

As yet, little is known about the effects of mental health stigma on sustainable employment. This is surprising, as mental health stigma is common, and because people with severe and common mental disorders are 7 and 3 times more likely to be unemployed, respectively, than people with no disorders. As the global lifetime prevalence of mental disorders is 29%, the high unemployment rates of people with these health problems constitute an important and urgent public health inequality problem that needs to be addressed.

Main text

The aim of this position paper is to illustrate the assumption that stigma contributes to the unemployment of people with mental illness and mental health issues with evidence from recent scientific studies on four problem areas, and to provide directions for future research. These four problem areas indicate that: (1) employers and line managers hold negative attitudes towards people with mental illness or mental health issues, which decreases the chances of people with these health problems being hired or supported; (2) both the disclosure and non-disclosure of mental illness or mental health issues can lead to job loss; (3) anticipated discrimination, self-stigma and the ‘Why Try’ effect can lead to insufficient motivation and effort to keep or find employment and can result in unemployment; and (4) stigma is a barrier to seeking healthcare, which can lead to untreated and worsened health conditions and subsequently to adverse occupational outcomes (e.g. sick leave, job loss).

Conclusions

The paper concludes that stigma in the work context is a considerable and complex problem, and that there is an important knowledge gap especially regarding the long-term effects of stigma on unemployment. To prevent and decrease adverse occupational outcomes in people with mental illness or mental health issues there is an urgent need for high quality and longitudinal research on stigma related consequences for employment. In addition, more validated measures specifically for the employment setting, as well as destigmatizing intervention studies are needed.