Exploring positive pathways to care for members of the UK Armed Forces receiving treatment for PTSD: a qualitative study

[Factors influencing patient competency and health care of service members of the German armed forces with deployment-related mental illness: A patient interview study]

BACKGROUND

The number of service members of the German armed forces suffering from deployment-related mental health problems is steadily rising. Preliminary studies have shown that less than 50 % seek professional help. There is little knowledge about the factors influencing the development of an adequate level of patient competence to cope with the complexity of the clinical picture and the care of people with operational disabilities in the interprofessional network.

METHODS

The article presents data gathered by semi-structured, guided interviews from 14 affected individuals analyzing salient beliefs about the perceived factors influencing their patient competence and care through the interprofessional network of supporters inside and outside the German armed forces. Data evaluation was carried out by means of content-structuring, qualitative content analysis using the method of deductive-inductive category formation.

FINDINGS

Based on the interviews conducted, we identified four groups of salient beliefs having an influence on patient competence: identify changes and limitations, recognize illness, redirect one's life, help shape one's life again, and four groups of salient beliefs having an influence on care: intangible / material support, medical supplies, psychosocial support, third-party support. All main topics could be assigned to three levels of influence (individual, individual-contextual, contextual) and stored with a total of 70 topics (codes).

INTERPRETATION

The development of an effective "social structure" was named by those affected as an important influencing factor. Family members, comrades, superiors, and military GPs appear to have a significant impact on patient competence and care. The respondents' opinions about the importance of internal factors such as the soldier's self-image and fear of stigmatization are consistent with previous findings. Structural factors like supply procedures were mentioned as specific German armed forces phenomena.

Exploring the impacts of perceived locus of control on post-traumatic stress disorder among disaster survivors: A systematic review

WHAT IS KNOWN ON THE SUBJECT?: It was previously reported that perceived external locus of control may exacerbate depressive symptoms, is associated with anxiety, boosts stress and general mental distress and weakens resilience against traumatic situations or difficulties. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Those with a higher external locus of control are more prone to develop PTSD symptoms since the perceived external locus of control is among the predictors of PTSD. An internal locus of control is considered important in preventing PTSD, although an external locus of control appears to be a variable that causes/increases the prevalence of PTSD. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is known that nurses are deployed in clinical and fieldwork during disaster and assume key roles both interventional practices and psychosocial education. Thus, it is of particular importance for mental health nurses to be aware of the locus of control in themselves, their colleagues, and the community before, during and after disasters to be able to combat the risk/presence of PTSD.

ABSTRACT

AIM: The present systematic review explored the impacts of perceived locus of control on PTSD among individuals experiencing disasters.

METHOD

This is a systematic review study carried out through a search of the relevant research published in English over the period December 2021 to April 2022. Accordingly, we sought the studies to review on the Web of Science, PubMed, Scopus, Cochrane and Google Scholar databases using the keywords "Child, Children, Adolescent, Adolescence, Adult, Aged, Elderly, Post-Traumatic Stress Disorder, PTSD, Internal-External Control, Locus of Control, Disasters, Natural Disasters."

RESULTS

A total of 1.011 studies were found in the five databases using the keywords above. Following the exclusions, the remaining six studies were recruited for this systematic review. The six studies in question addressed earthquakes (2), hurricanes (1), wildfires (1), SARS (1) and fireworks explosions (1). In the study with wildfire survivors, there was a weak significant association between external locus of control and PTSD among those directly exposed to the disaster (r = .15, p < .01). The study with survivors of the SARS epidemic demonstrated that those with a high perceived chance (external) locus of control suffered PTSD (p = .001). An internal locus of control is considered important in preventing PTSD, although an external locus of control appears to be a variable that causes/increases the prevalence of PTSD.

CONCLUSION

It was concluded that perceived locus of control is related to PTSD in individuals experiencing a disaster. The additional evidence was that post-disaster PTSD among those with a high perceived external locus of control is stronger than those with a high perceived internal locus of control.

Exploration of Trauma-Oriented Retreats: Quantitative Changes in Mental Health Measures for Canadian Military Members, Veterans and Royal Canadian Mounted Police with Posttraumatic Stress Disorder and Moral Injury

Background: Military members, veterans, and public safety personnel have been noted to have a higher risk of exposure to potentially traumatic events and potentially morally injurious events resulting in operational stress injuries (OSI) such as posttraumatic stress disorder (PTSD) and moral injury (MI). Treatments that can quickly and effectively address these conditions are desperately needed. The purpose of this research was to identify the impact of participation in a non-evidence-based trauma-oriented retreat for the above populations experiencing PTSD and MI. Methods: This study was an embedded mixed-methods longitudinal study with parallel repeated quantitative measures designed to evaluate outcomes at 1, 3, 6, and 12 months after completion of the retreat. Results: Analysis showed a statistically significant reduction in self-reported symptoms of PTSD, anxiety, stress, depression, MI, anger, and emotional dysregulation pre/post-retreat, and an increase in resilience. Self-reported longitudinal results did not see a change in symptom scores, with participants continuing to maintain their clinical diagnoses post-retreat. Conclusions: The results from this study illustrate that trauma-oriented retreats may be a complementary treatment modality for OSI-related conditions but should not be seen as a first-line treatment option. Program evaluation, determination of the evidence-based nature of retreats, and standardization are yet needed.

Seeking treatment for mental illness and substance abuse: A cross-sectional study on attitudes, beliefs, and needs of military personnel with and without mental illness

BACKGROUND

Often, military personnel do not seek treatment for mental illness or wait until they reach a crisis point. Effective, selective, and indicated prevention is best achieved by seeking treatment early.

AIMS

We aimed to examine military personnel's attitudes, beliefs, and needs around seeking treatment for mental illness. We compared those who sought treatment to those who did not and those with and without the intention to seek treatment. Finally, we examined factors associated with intentions of not seeking treatment.

METHOD

We conducted a cross-sectional questionnaire study of military personnel with (N = 324) and without (N = 554) mental illness. Descriptive and regression analyses (logistic and ordinal) were performed.

RESULTS

The majority of the personnel believed treatment was effective (91.6%); however, most preferred to solve their own problems (66.0%). For personnel with mental illness, compared to those who sought treatment, those who did not had a higher preference for self-management and found advice from others less important. For those without mental illness, those with no intention to seek treatment indicated a higher preference for self-management, stigma-related concerns, denial of symptoms, lower belief in treatment effectiveness and found it less important to be an example, compared to those with treatment-seeking intentions. A clear indication of where to seek help was the most reported need (95.7%). Regression analyses indicated that not seeking treatment was most strongly related to preference for self-management (OR(95%CI) = 4.36(2.02-9.39); no intention to seek treatment was most strongly related to a lower belief that treatment is effective (OR(95%CI) = .41(0.28-0.59) and with not having had positive earlier experiences with treatment seeking (OR(95%CI) = .34(0.22-0.52).

CONCLUSIONS

To facilitate (early) treatment seeking, interventions should align with a high preference for self-management, mental illness stigma should be targeted, and a clear indication of where to seek treatment is needed.

"My heart on this bit of paper": A grounded theory of the mechanisms of change in art therapy for military veterans

BACKGROUND

A proportion of veterans experience post-traumatic stress disorder (PTSD). Research has shown reduced effectiveness of commonly offered psychotherapies in military personnel. Some research suggested the usefulness of art therapy for veterans with PTSD, but its mechanism of operation has been unclear. The current project aimed to establish participants' perceptions of any impact of group art therapy and some of the perceived mechanisms of change.

METHOD

In a grounded theory design, single semi-structured interviews were conducted with nine veterans who had received group art therapy, two art therapists, and a veteran's wife. Interviews were transcribed and analysed.

FINDINGS

Theorised categories included (a) art therapy group as "the family", (b) "the gentle conductor", (c) trust, (d) doing the work, (e) art therapy as "a communication tool", (f) "points of recognition", (g) "making things concrete", and (h) "not a cure".

LIMITATIONS

Shortcomings included a homogenous sample who all attended art therapy alongside other interventions, reliance on subjective and unmeasured symptom change, and researcher effects related to qualitative methodology.

CONCLUSION

The developed grounded theory is consistent with existing evidence and neuropsychological theory. Group art therapy may enable some veterans to prepare for verbal-only therapy, by offering a safe space in which to approach non-verbal traumatic and trauma-related contextual material in a controlled way. Artworks may provide a bridge to facilitate communication of experiences within subsequent verbal therapy and with loved-ones. It is suggested to replicate the project at different sites. Elements of the developed theory may be investigated further to establish its transferability.

Predictors of Treatment Access and Initiation Among Diverse, Low-Income Victims of Violence Offered a Trauma-Focused Evidence-Based Psychotherapy

Many victims of violence may benefit from trauma-focused evidence-based psychotherapies (EBPs), but fail to utilize treatment. The current study investigated factors associated with treatment access and treatment initiation in a low-income, racially and ethnically diverse, urban population of victims of violence who were screened for EBPs. The sample consisted of 941 adults, mean age = 35.87 (SD = 12.8), who were screened for mental health treatment and offered an EBP. Overall, 55.7% of individuals accessed treatment by attending an in-person screening appointment and intake, and 79.0% of the individuals who accessed treatment then initiated treatment by attending the first EBP session. Analysis revealed higher age (odds ratio [OR] = 1.05, 95% confidence interval (CI) = [1.04, 1.09]) and lower expression of posttraumatic stress disorder (PTSD) symptoms predicted higher rates of accessing treatment (OR = 0.20, 95% CI = [0.05, 0.82]). Higher global severity of distress (OR = 3.22, 95% CI = [1.14, 9.10]), poor quality of life in the area of psychological health (OR = 0.90, 95% CI = [0.81, 1.00]), and better quality of life in the area of physical health significantly predicted initiation of treatment (OR = 1.11, 95% CI = [0.998, 1.24]). Findings suggest that low-income, ethnically and racially diverse victims of violence may effectively utilize trauma-focused EBPs offered in a community setting.

Integrated Trauma-Focused Cognitive Behavioral Therapy for Comorbid Combat-Related Posttraumatic Stress Disorder: A Case Study with a Military Veteran

Individual Trauma-focused CBT has been shown to be effective for treating posttraumatic stress disorder in military veterans. Treatment challenges are common including the presence of dissociation and comorbidities including depression, traumatic brain injury symptoms, substance misuse, and social transition difficulties. There are currently no standard psychological therapy guidelines for veterans with comorbid presentations. However, as recommended by the National Institute for Health and Care Excellence treatment guidelines, adapting existing treatments can improve the chances of successfully treating trauma cases. In line with these recommendations, the current case study describes how the existing individual trauma-focused CBT model was integrated to treat posttraumatic stress disorder with comorbid depression, persistent mild-traumatic brain injury migraine, and social transition difficulties in a 38-year-old male combat veteran. The client attended 16-sessions of trauma-focused CBT. This model integrated his comorbidities and involved his spouse and multidisciplinary discussions with his general practitioner, and neurorehabilitation team and the Veterans’ Transition Service. At the end of treatment, the client no longer met the diagnostic criteria for posttraumatic stress disorder. This case illustrates how trauma-focused CBT can be integrated to treat comorbid posttraumatic stress disorder in veterans.

Barriers and facilitators for treatment-seeking for mental health conditions and substance misuse: multi-perspective focus group study within the military

BACKGROUND

Globally, millions are exposed to stressors at work that increase their vulnerability to develop mental health conditions and substance misuse (such as soldiers, policemen, doctors). However, these types of professionals especially are expected to be strong and healthy, and this contrast may worsen their treatment gap. Although the treatment gap in the military has been studied before, perspectives of different stakeholders involved have largely been ignored, even though they play an important role.

AIMS

To study the barriers and facilitators for treatment-seeking in the military, from three different perspectives.

METHOD

In total, 46 people participated, divided into eight homogeneous focus groups, including three perspectives: soldiers with mental health conditions and substance misuse (n = 20), soldiers without mental health conditions and substance misuse (n = 10) and mental health professionals (n = 16). Sessions were audio-taped and transcribed verbatim. Content analysis was done by applying a general inductive approach using ATLAS.ti-8.4.4 software.

RESULTS

Five barriers for treatment-seeking were identified: fear of negative career consequences, fear of social rejection, confidentiality concerns, the 'strong worker' workplace culture and practical barriers. Three facilitators were identified: social support, accessibility and knowledge, and healthcare within the military. The views of the different stakeholder groups were highly congruent.

CONCLUSIONS

Barriers for treatment-seeking were mostly stigma related (fear of career consequences, fear of social rejection and the 'strong worker' workplace culture) and this was widely recognised by all groups. Social support from family, peers, supervisors and professionals were identified as important facilitators. A decrease in the treatment gap for mental health conditions and substance misuse is needed and these findings provide direction for future research and destigmatising interventions.

Symptom Severity, Self-efficacy and Treatment-Seeking for Mental Health Among US Iraq/Afghanistan Military Veterans

Military veterans have high rates of mental health problems, yet the majority do not seek treatment. Understanding treatment-seeking in this population is important. This study investigated if symptom severity and self-efficacy are associated with treatment-seeking among US Iraq/Afghanistan veterans. Survey data from 525 veterans meeting clinical criteria for PTSD and depression were included of which, 54.4% had sought treatment in the past 12 months. Multivariate logistic regression analysis indicated that high symptom severity was associated with treatment seeking, whereas high self-efficacy was associated with a decreased likelihood to seek treatment. Self-efficacy could be an underlying mechanism of treatment seeking decisions.

Barriers and Facilitators to Help-Seeking for Individuals With Posttraumatic Stress Disorder: A Systematic Review

Posttraumatic stress disorder (PTSD) brings with it diagnostic symptoms that can be debilitating and persist for years. Left untreated, PTSD can have far-reaching and damaging consequences for the individual, families, communities, and society at large. Although early detection and intervention are recognized as key to the effective treatment of PTSD, many individuals who suffer from PTSD do not seek essential health services. The aim of the present study was to identify the barriers and facilitators to help-seeking for individuals with PTSD, based on existing literature. A systematic review, modeled on the Joanna Briggs Institute methodology for systematic reviews, examined studies cited in PsycINFO, Medline, Embase, CINAHL, and PILOTS published from January 1980 to January 2019. Eligible studies measured barriers and facilitators to help-seeking for adults with PTSD. Two reviewers independently screened citations, and double data extraction was exercised. Of 2,391 potentially relevant citations, 21 studies, published between 1989 and 2018 and based in six countries, were included. Seventeen studies focused on military as a target population. We identified 10 principal barrier and facilitator themes: trauma-related; treatment; therapist or provider; knowledge; access; health care system; sociocultural environment; values, beliefs, and priorities; past experiences; and medical care needs and illness burden. In identifying prominent barriers and facilitators to help-seeking for individuals with PTSD, this review highlights opportunities to inform policies and programs that promote PTSD knowledge and recognition, reduce public and personal stigma, improve access and quality of care, and encourage support for patients and families living with PTSD.

Differences between the Canadian military's Regular and Reserve Forces in perceived need for care, mental health services use and perceived sufficiency of care: a cross-sectional survey

OBJECTIVE

The primary objective was to explore differences in perceived need for care (PNC), mental health services use (MHSU) and perceived sufficiency of care (PSC) between Canadian Armed Forces Regular Force (RegF) and Reserve Force (ResF) personnel with an objective need for mental health services.

DESIGN

Data came from the 2013 Canadian Armed Forces Mental Health Survey, a cross-sectional survey of serving personnel (n=72 629). Analyses were among those with an Afghanistan deployment and an identified mental disorder (population n=6160; sampled n=868). Logistic regression compared PNC, MHSU and PSC between RegF and ResF. Covariate-adjusted marginal prevalence difference estimates were computed.

PRIMARY OUTCOME MEASURE

The primary outcomes were PNC, MHSU and PSC. Each had three service categories, including an aggregate 'any' of the three: (1) information about problems, treatments or services; (2) medication and (3) counselling.

RESULTS

ResF had an 10.5% (95% CI -16.7% to -4.4%) lower perceived need for medication services but PNC differences were not significant for other service categories. MHSU tended to be lower for ResF; 9.1% (95%CI -15.5% to -2.6%) lower for medication, 5.4% (95% CI -11.5% to 0.7%) lower, with marginal significance, for counselling and 11.3% (95% CI -17.3% to -5.2%) lower for the 'any' service category. Additionally, ResF tended to have a lower fully met need for care; 13.4% (95% CI -22.1% to -4.6%) lower for information, 15.3% (95% CI -22.9% to -7.6%) lower for counselling and 14.6% (95% CI -22.4% to -6.8%) lower for the 'any' service category.

CONCLUSIONS

Our findings suggest MHSU and PSC differences between Canadian RegF and ResF personnel that are not fully accounted for by PNC differences. Deficits in ResF members' perceptions of the sufficiency of information services and counselling services suggest perceived, or experienced, barriers to care beyond any PNC barriers. Additional research assessing barriers to mental healthcare is warranted.

Mental Health Service Utilization in Depressed Canadian Armed Forces Personnel

BACKGROUND

Major depression is prevalent, impactful, and treatable in military populations, but not all depressed personnel seek professional care in a given year. Care-seeking patterns (including the use of primary vs. specialty care) and factors associated with the likelihood of mental health service utilization in depressed military personnel are poorly understood.

METHODS

Our sample included 520 Regular Force respondents to the 2013 Canadian Forces Mental Health Survey. All study participants had past-year major depression. Subjects reported whether they had spoken about their mental health with at least one health professional in the past 12 months. We used multivariate Poisson regression to explore factors associated with past-year mental health service use.

RESULTS

Three-quarters of Canadian military personnel with past-year depression had sought mental health care in the previous 12 months. Among care-seeking personnel, 70% had seen a psychologist or psychiatrist, while 5% had exclusively received care from a primary care physician. Belief in the effectiveness of mental health care was the factor most strongly associated with care seeking. Female gender, functional impairments, and psychiatric comorbidities were also associated with care seeking. Surprisingly, stigma perceptions had no independent association with care seeking.

CONCLUSIONS

The proportion of depressed Canadian Armed Forces personnel who seek professional care and who access specialty mental health care is higher than in most other populations. However, an important minority of patients are not accessing health services. Efforts to further increase mental health service utilization in the Canadian military should continue to target beliefs about the effectiveness of mental health care.

Mental Health, Help-Seeking Behaviour and Social Support in the UK Armed Forces by Gender

Background: Little is known about gender differences in mental health, related help-seeking behavior and social support in UK military personnel. Methods: 1714 UK military serving personnel and ex-service veterans were randomly selected if, in a cohort study, they endorsed experiencing a subjective stress, emotional, alcohol or mental health problem in the previous three years. Following exclusions, the final sample size was 1448 (participation rate 84.5%; women n = 219). Structured telephone interviews assessed anxiety, depression, PTSD symptoms, alcohol use, help-seeking and social support occurring both currently and in the past three years. Outcomes were assessed using weighted unadjusted and adjusted logistic regression analyses. Results: Mental health problems assessed at interview were broadly similar for men and women; for both genders, levels of social support were high. One-fifth of respondents screened positive for probable mental disorder or alcohol misuse; although rates of mental disorder symptoms did not differ by gender, women were significantly less likely than men to report alcohol misuse. Women were significantly more likely to have sought help from formal medical sources but significantly less likely to access informal support such as friends, family or unit welfare sources; reasons for seeking formal medical support were similar for men and women except for problem recognition and acting on advice from others, which were both significantly more common among women. Conclusion: For military personnel with a history of mental ill-health, women should make greater use of informal support networks while for men, engagement with formal medical help sources should be encouraged.

Locus of control in US combat veterans: Unique associations with posttraumatic stress disorder 5-factor model symptom clusters

Given elevated rates of posttraumatic stress disorder (PTSD) among US military veterans, identifying correlates of PTSD and specific PTSD symptom clusters that best represent PTSD in veterans (i.e., the five-factor Dysphoric Arousal model) is critical to prevention and intervention efforts. One potential correlate is locus of control (i.e., the extent to which individuals believe they have control over events in their lives). The aim of this study was to examine the relations between locus of control and five-factor model PTSD symptom clusters (i.e., re-experiencing, avoidance, numbing, dysphoric arousal, anxious arousal) among combat veterans. Eighty-nine combat exposed veterans completed self-report measures of demographics, locus of control, PTSD symptoms, and combat exposure. Bivariate correlations indicated relations between locus of control and overall PTSD symptoms, avoidance symptoms, and numbing symptoms. When controlling for sex and combat exposure in regression analyses, only avoidance remained a significant correlate of locus of control. Among veterans with the most extreme scores (n = 26), external locus of control predicted overall PTSD symptoms and avoidance symptoms. External locus of control is uniquely associated with avoidance symptoms, and represents a potentially modifiable factor to address in trauma-focused treatments.

Attributions and private theories of mental illness among young adults seeking psychiatric treatment in Nairobi: an interpretive phenomenological analysis

BACKGROUND

Mental illness affects every segment of population including young adults. The beliefs held by young patients regarding the causes of mental illness impact their treatment-seeking behaviour. It is pertinent to know the commonly held attributions around mental illness so as to effectively provide psychological care, especially in a resource constrained context such as Kenya. This helps in targeting services around issues such as stigma and extending youth-friendly services.

METHODS

Guided by the private theories interview (PTI-P) and attributional framework, individual semi-structured interviews were carried out with ten young adults of ages 18-25 years about their mental health condition for which they were undergoing treatment. Each interview took 30-45 min. We mapped four attributions (locus of control, stability, controllability and stigma) on PTI-P questions. Data was transcribed verbatim to produce transcripts coded using interpretive phenomenological analysis. These codes were then broken down into categories that could be used to understand various attributions.

RESULTS

We found PTI-P to be a useful tool and it elicited three key themes: (a) psychosocial triggers of distress (with themes of negative thoughts, emotions around mental health stigma and negative childhood experiences, parents' separation or divorce, death of a loved one etc.), (b) biological conditions and psychopathologies limiting intervention, and (c) preferences and views on treatment. Mapping these themes on our attributional framework, PTI-P themes presented as causal attributions explaining stigma, locus of control dimensions and stability. External factors were mainly ascribed to be the cause of unstable and uncontrollable attributions including persistent negative emotions and thoughts further exacerbating psychological distress. Nine out of the ten participants expressed the need for more intense and supportive therapy.

CONCLUSION

Our study has provided some experiential evidence in understanding how stigma, internal vs external locus of control, stability vs instability attributions play a role in shaping attitudes young people have towards their mental health. Our study points to psychosocial challenges such as stigma, poverty and lack of social support that continue to undermine mental well-being of Kenyan youth. These factors need to be considered when addressing mental health needs of young people in Kenya.

Influence of military component and deployment-related experiences on mental disorders among Canadian military personnel who deployed to Afghanistan: a cross-sectional survey

OBJECTIVE

The primary objective was to explore differences in mental health problems (MHP) between serving Canadian Armed Forces (CAF) components (Regular Force (RegF); Reserve Force (ResF)) with an Afghanistan deployment and to assess the contribution of both component and deployment experiences to MHP using covariate-adjusted prevalence difference estimates. Additionally, mental health services use (MHSU) was descriptively assessed among those with a mental disorder.

DESIGN

Data came from the 2013 CAF Mental Health Survey, a cross-sectional survey of serving personnel (n=72 629). Analyses were limited to those with an Afghanistan deployment (population n=35 311; sampled n=4854). Logistic regression compared MHP between RegF and ResF members. Covariate-adjusted prevalence differences were computed.

PRIMARY OUTCOME MEASURE

The primary outcomes were MHP, past-year mental disorders, identified using the WHO's Composite International Diagnostic Interview, and past-year suicide ideation.

RESULTS

ResF personnel were less likely to be identified with a past-year anxiety disorder (adjusted OR (AOR)=0.72 (95% CI 0.58 to 0.90)), specifically both generalised anxiety disorder and panic disorder, but more likely to be identified with a past-year alcohol abuse disorder (AOR=1.63 (95% CI 1.04 to 2.58)). The magnitude of the covariate-adjusted disorder prevalence differences for component was highest for the any anxiety disorder outcome, 2.8% (95% CI 1.0 to 4.6); lower for ResF. All but one deployment-related experience variable had some association with MHP. The 'ever felt responsible for the death of a Canadian or ally personnel' experience had the strongest association with MHP; its estimated covariate-adjusted disorder prevalence difference was highest for the any (of the six measured) mental disorder outcome (11.2% (95% CI 6.6 to 15.9)). Additionally, ResF reported less past-year MHSU and more past-year civilian MHSU.

CONCLUSIONS

Past-year MHP differences were identified between components. Our findings suggest that although deployment-related experiences were highly associated with MHP, these only partially accounted for MHP differences between components. Additional research is needed to further investigate MHSU differences between components.

Pathways into mental health care for UK veterans: a qualitative study

Background: It is well established that veterans suffering from mental health difficulties under use mental health services. Objective: This study aimed to understand more about the barriers that prevent veterans from seeking professional help and the enablers that assist veterans in seeking professional help. It also aimed to explore potential mechanisms to improve veterans' help-seeking and pathways to care. Method: The study employed a qualitative design whereby 17 veterans who had recently attended specialist veteran mental health services took part in semi-structured interviews. The resultant data were analysed using grounded theory. Results: Participants described two distinct stages to their help-seeking: initial help-seeking and pathways through treatment. Specific barriers and enablers to help-seeking were identified at each stage. Initial barriers included recognizing that there is a problem, self-stigma and anticipated public stigma. Initial enablers included being in crisis, social support, motivation and the media. Treatment pathway barriers included practical factors and negative beliefs about health services and professionals. Treatment pathway enablers included having a diagnosis, being seen in a veteran-specific service and establishing a good therapeutic relationship. Participants provided some suggestions for interventions to improve veterans' help-seeking in future; these focussed on enhancing both veterans and health professionals' knowledge regarding mental health difficulties. Conclusions: This study identified a number of barriers and enablers that may impact a veteran's journey in seeking help from professional services for mental health difficulties. Enablers such as reaching a crisis point, social support, the media, having a diagnosis of PTSD and veteran-specific mental health services appeared to be important in opposing stigma-related beliefs and in supporting veterans to engage in help-seeking behaviours.

Military veteran engagement with mental health and well-being services: a qualitative study of the role of the peer support worker

Background: Many UK military veterans experiencing mental health and well-being difficulties do not engage with support services to get the help they need. Some mental health clinics employ Peer Support Workers (PSWs) to help veteran patients engage, however it is not known how the role influences UK veteran engagement.Aims: To gain insight into the role of peer support in UK veteran engagement with mental health and well-being services.Method: A qualitative study based on 18 semi-structured interviews with veterans, PSWs and mental health clinicians at a specialist veteran mental health and well-being clinic in Scotland.Results: Four themes of the PSW role as positive first impression, understanding professional friend, helpful and supportive connector, and an open door were identified across all participants. The PSWs' military connection, social and well-being support and role in providing veterans with an easily accessible route to dis-engage and re-engage with the service over multiple engagement attempts were particularly crucial.Conclusions: The Peer Support role enhanced veteran engagement in the majority of instances. Study findings mirrored existing peer support literature, provided new evidence in relation to engaging UK veterans, and made recommendations for future veteran research and service provision.

Stigma-related barriers and facilitators to help seeking for mental health issues in the armed forces: a systematic review and thematic synthesis of qualitative literature

A recent quantitative review in the area of stigma and help seeking in the armed forces has questioned the association between these factors (Sharp et al. 2015). To date, the contribution of qualitative literature in this area has largely been ignored, despite the value this research brings to the understanding of complex social constructs such as stigma. The aim of the current systematic review of qualitative studies was to identify appropriate literature, assess the quality and synthesize findings across studies regarding evidence of stigma-related barriers and facilitators to help seeking for mental health issues within the armed forces. A multi-database text word search incorporating searches of PsycINFO, MEDLINE, Social Policy and Practice, Social Work Abstracts, EMBASE, ERIC and EBM Review databases between 1980 and April 2015 was conducted. Literature was quality assessed using the Critical Appraisal Skills Programme tool. Thematic synthesis was conducted across the literature. The review identified eight studies with 1012 participants meeting the inclusion criteria. Five overarching themes were identified across the literature: (1) non-disclosure; (2) individual beliefs about mental health; (3) anticipated and personal experience of stigma; (4) career concerns; and (5) factors influencing stigma. The findings from the current systematic review found that unlike inconsistent findings in the quantitative literature, there was substantial evidence of a negative relationship between stigma and help seeking for mental health difficulties within the armed forces. The study advocates for refinement of measures to accurately capture the complexity of stigma and help seeking in future quantitative studies.

[Barriers to treatment-seeking among German veterans: expert interviews]

BACKGROUND

The number of service members of the German armed forces suffering from deployment-related mental health problems is increasing. However, less than 50 % seek professional help, and there is little knowledge about the barriers to treatment-seeking.

METHODS

The article presents data gathered by the Delphi technique combined with focus groups from 55 health service experts regarding the evaluated barriers to treatment-seeking among German veterans.

FINDINGS

According to the interviewed experts, major contextual barriers to treatment-seeking include: 1) intimidating processes and structures, 2) actual stigmatization and discrimination, and 3) health service deficits. Major individual barriers to treatment were: 4) health beliefs, self-perception and fear of stigmatization, and 5) avoidance behavior related to psychopathology. In addition, there is another both contextual and individual barrier, i.e., 6) information deficits.

INTERPRETATION

Individual internal factors like the soldiers' self-perception and their fear of being stigmatized were considered important barriers to treatment-seeking. The experts' opinion about avoidance behavior related to psychopathology and deficits in health services and information coincides with international findings. Compared to research in other countries, actual stigmatization and discrimination were regarded to be an important barrier in itself. According to our findings daunting/intimidating processes and structures like time-consuming and complex expert medical reports rather seem to be a German phenomenon.

Exploring optimum cut-off scores to screen for probable posttraumatic stress disorder within a sample of UK treatment-seeking veterans

Background: Previous research exploring the psychometric properties of the scores of measures of posttraumatic stress disorder (PTSD) suggests there is variation in their functioning depending on the target population. To date, there has been little study of these properties within UK veteran populations. Objective: This study aimed to determine optimally efficient cut-off values for the Impact of Event Scale-Revised (IES-R) and the PTSD Checklist for DSM-5 (PCL-5) that can be used to assess for differential diagnosis of presumptive PTSD. Methods: Data from a sample of 242 UK veterans assessed for mental health difficulties were analysed. The criterion-related validity of the PCL-5 and IES-R were evaluated against the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Kappa statistics were used to assess the level of agreement between the DSM-IV and DSM-5 classification systems. Results: The optimal cut-off scores observed within this sample were 34 or above on the PCL-5 and 46 or above on the IES-R. The PCL-5 cut-off is similar to the previously reported values, but the IES-R cut-off identified in this study is higher than has previously been recommended. Overall, a moderate level of agreement was found between participants screened positive using the DSM-IV and DSM-5 classification systems of PTSD. Conclusions: Our findings suggest that the PCL-5 and IES-R can be used as brief measures within veteran populations presenting at secondary care to assess for PTSD. The use of a higher cut-off for the IES-R may be helpful for differentiating between veterans who present with PTSD and those who may have some sy`mptoms of PTSD but are sub-threshold for meeting a diagnosis. Further, the use of more accurate optimal cut-offs may aid clinicians to better monitor changes in PTSD symptoms during and after treatment.

Mental Health Treatment Among Soldiers With Current Mental Disorders in the Army Study to Assess Risk and Resilience in Service Members (Army STARRS)

A representative sample of 5,428 nondeployed Regular Army soldiers completed a self-administered questionnaire (SAQ) and consented to linking SAQ data with administrative records as part of the Army Study to Assess Risk and Resilience in Service members. The SAQ included information about prevalence and treatment of mental disorders among respondents with current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) internalizing (anxiety, mood) and externalizing (disruptive behavior, substance) disorders. 21.3% of soldiers with any current disorder reported current treatment. Seven significant predictors of being in treatment were identified. Four of these 7 were indicators of psychopathology (bipolar disorder, panic disorder, post-traumatic stress disorder, 8+ months duration of disorder). Two were sociodemographics (history of marriage, not being non-Hispanic Black). The final predictor was history of deployment. Treatment rates varied between 4.7 and 71.5% depending on how many positive predictors the soldier had. The vast majority of soldiers had a low number of these predictors. These results document that most nondeployed soldiers with mental disorders are not in treatment and that untreated soldiers are not concentrated in a particular segment of the population that might be targeted for special outreach efforts. Analysis of modifiable barriers to treatment is needed to help strengthen outreach efforts.

Mental Health Difficulties and Help-Seeking Beliefs within a Sample of Female Partners of UK Veterans Diagnosed with Post-Traumatic Stress Disorder

In the UK there is a paucity of research about the needs of partners who are supporting ex-service personnel with mental health difficulties. In this study, we surveyed the mental health needs and barriers to help-seeking within a sample of partners of UK veterans who had been diagnosed with PTSD. Our sample included 100 participants. Forty-five percent met criteria for alcohol problems, 39% for depression, 37% for generalised anxiety disorder and 17% for symptoms of probable PTSD. Participants who met case criteria for depression, anxiety and problems with alcohol were more likely to report a greater number of help-seeking barriers. Participants who were experiencing mental health difficulties were more likely to endorse barriers connected to stigmatising beliefs than those associated with practical issues around accessing mental health services. The evidence presented suggests there may be a considerable burden of mental illness within this population. It would seem prudent to conduct further work to understand how best to address this clinical need.

A service evaluation of self-referral to military mental health teams

BACKGROUND

The UK military runs a comprehensive mental health service ordinarily accessed via primary care referrals.

AIMS

To evaluate the feasibility of self-referral to mental health services within a military environment.

METHODS

Three pilot sites were identified; one from each service (Royal Navy, Army, Air Force). Socio-demographic information included age, rank, service and career duration. Clinical data included prior contact with general practitioner (GP), provisional diagnosis and assessment outcome.

RESULTS

Of the 57 self-referrals, 69% (n = 39) had not previously accessed primary care for their current difficulties. After their mental health assessment, 47 (82%) were found to have a formal mental health problem and 41 (72%) were offered a further mental health clinician appointment. The data compared favourably with a large military mental health department that reported 87% of primary care referrals had a formal mental health condition.

CONCLUSIONS

The majority of self-referrals had formal mental health conditions for which they had not previously sought help from primary care; most were offered further clinical input. This supports the view that self-referral may be a useful option to encourage military personnel to seek professional care over and above the usual route of accessing care through their GP.

Functional neuroimaging with default mode network regions distinguishes PTSD from TBI in a military veteran population

PTSD and TBI are two common conditions in veteran populations that can be difficult to distinguish clinically. The default mode network (DMN) is abnormal in a multitude of neurological and psychiatric disorders. We hypothesize that brain perfusion SPECT can be applied to diagnostically separate PTSD from TBI reliably in a veteran cohort using DMN regions. A group of 196 veterans (36 with PTSD, 115 with TBI, 45 with PTSD/TBI) were selected from a large multi-site population cohort of individuals with psychiatric disease. Inclusion criteria were peacetime or wartime veterans regardless of branch of service and included those for whom the traumatic brain injury was not service related. SPECT imaging was performed on this group both at rest and during a concentration task. These measures, as well as the baseline-concentration difference, were then inputted from DMN regions into separate binary logistic regression models controlling for age, gender, race, clinic site, co-morbid psychiatric diseases, TBI severity, whether or not the TBI was service related, and branch of armed service. Predicted probabilities were then inputted into a receiver operating characteristic analysis to compute sensitivity, specificity, and accuracy. Compared to PSTD, persons with TBI were older, male, and had higher rates of bipolar and major depressive disorder (p < 0.05). Baseline quantitative regions with SPECT separated PTSD from TBI in the veterans with 92 % sensitivity, 85 % specificity, and 94 % accuracy. With concentration scans, there was 85 % sensitivity, 83 % specificity and 89 % accuracy. Baseline-concentration (the difference metric between the two scans) scans were 85 % sensitivity, 80 % specificity, and 87 % accuracy. In separating TBI from PTSD/TBI visual readings of baseline scans had 85 % sensitivity, 81 % specificity, and 83 % accuracy. Concentration scans had 80 % sensitivity, 65 % specificity, and 79 % accuracy. Baseline-concentration scans had 82 % sensitivity, 69 % specificity, and 81 % accuracy. For separating PTSD from PTSD/TBI baseline scans had 87 % sensitivity, 83 % specificity, and 92 % accuracy. Concentration scans had 91 % sensitivity, 76 % specificity, and 88 % accuracy. Baseline-concentration scans had 84 % sensitivity, 64 % specificity, and 85 % accuracy. This study demonstrates the ability to separate PTSD and TBI from each other in a veteran population using functional neuroimaging.

Medical and Welfare Officers beliefs about post-deployment screening for mental health disorders in the UK Armed Forces: a qualitative study

Background

This study aimed to examine currently serving United Kingdom (UK) military Medical and Welfare Officers views on the potential introduction of post-deployment screening for mental ill health.

Methods

Semi-structured interviews were conducted with 21 Medical and Welfare Officers. Interview transcripts were analysed using data-driven thematic analysis.

Results

Four themes were identified: positive views of screening; reliability of responses; impact on workload; and suggestions for implementation. Interviewees viewed the introduction of screening post-deployment as likely to increase awareness of mental health problems whilst also reporting that service personnel were likely to conceal their true mental health status by providing misleading responses to any screening tool. Concern over reliability of responses may provide one explanation for the reluctance of service personnel to seek help for problems, as they could feel they will not be taken seriously. Welfare Officers felt they would not have the knowledge or experience to respond to help-seeking. Although participants were concerned about potential impact on their personal workload, they indicated a desire to positively engage with the screening programme if research showed it was an effective tool to improve mental health care.

Conclusions

Welfare and healthcare providers are well disposed towards a screening programme for mental health but highlight a few concerns in its implementation. In particular Welfare Officers appear to require more training in how to respond to mental ill health. Concerns about available funding and resources to respond to increased workload will need to be addressed should post-deployment screening for mental health be introduced in the UK military.

Mental health and functional impairment outcomes following a 6-week intensive treatment programme for UK military veterans with post-traumatic stress disorder (PTSD): a naturalistic study to explore dropout and health outcomes at follow-up

OBJECTIVE

Combat Stress, a UK national charity for veterans with mental health problems, has been funded by the National Health Service (NHS) to provide a national specialist service to deliver treatment for post-traumatic stress disorder (PTSD). This paper reports the efficacy of a PTSD treatment programme for UK veterans at 6 months follow-up.

DESIGN

A within subject design.

SETTING

UK veterans with a diagnosis of PTSD who accessed Combat Stress.

PARTICIPANTS

246 veterans who received treatment between late 2012 and early 2014.

INTERVENTION

An intensive 6-week residential treatment programme, consisting of a mixture of individual and group sessions. Participants were offered a minimum of 15 individual trauma-focused cognitive behavioural therapy sessions. In addition, participants were offered 55 group sessions focusing on psychoeducational material and emotional regulation.

MAIN OUTCOME MEASURES

Clinicians completed measures of PTSD and functional impairment and participants completed measures of PTSD, depression, anger and functional impairment.

RESULTS

We observed significant reductions in PTSD scores following treatment on both clinician completed measures (PSS-I: -13.0, 95% CI -14.5 to -11.5) and self-reported measures (Revised Impact of Events Scale (IES-R): -16.5, 95% CI -19.0 to -14.0). Significant improvements in functional impairment were also observed (eg, Health of the Nation Outcome Scales (HONOS): -6.85, 95% CI -7.98 to -5.72). There were no differences in baseline outcomes between those who completed and those who did not complete the programme, or post-treatment outcomes between those we were able to follow-up at 6 months and those lost to follow-up.

CONCLUSIONS

In a naturalistic study we observed a significant reduction in PTSD scores and functional impairment following treatment. These improvements were maintained at 6 month follow-up. Our findings suggest it may be helpful to take a closer look at combining individual trauma-focused cognitive behaviour therapy and group sessions when treating veterans with PTSD. This is the first UK study of its kind, but requires further evaluation.