MILITARY MEDICINE, 179, 3;273, 2014
A Survey of Perceived Barriers and Attitudes Toward Mental Health Care Among OEF/OIF Veterans at VA Outpatient Mental Health Clinics Hector A. Garcia, PsyD*t; Erin P. Finiey, PhD, MPH*ft; Norma Ketchum, MS§; Matthew Jakupcak, PhDJI; Aibana Dassori, MD*t; Stephanie C. Reyes, BAJj ABSTRACT Objective: In an effort to improve our understanding of perceived treatment barriers among veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) relative to other era veterans, the current study examined veteran attitudes and beliefs about mental health treatment and treatment-seeking, and perceived patient and institutionlevel logistical barriers to care. Method: A survey was conducted among 434 Combat veterans seeking care in nine Veterans Affairs mental health care outpatient clinics. Results: When compared to Vietnam and Gulf War veterans, OEF/OIF veterans were significantly more likely to endorse negative treatment attitudes as possible barriers to care. OEF/OIF veterans were also more likely than Vietnam veterans to endorse conflicting work demands as a potential barrier, although this was the only logistical barrier for which OEF/OIF veterans' responses differed significantly from those of veterans of other eras. Among OEF/OIF veterans, older veterans were more likely than younger veterans to endorse barriers related to cost and time commitments. Conclusions: These findings suggest an important role for outreach and engagement strategies that address attitudinal barriers to treatment utilization among veteran populations.
INTRODUCTION Since September 11, 2001, upwards of two million U.S. veterans have served in support of Operations Enduring and Iraqi Freedom (OEF/OIF).' In this growing population of veterans, studies examining the mental health impact of combat deployment have identified significant rates of post-traumatic stress disorder (PTSD),^""^ depression,"' alcohol-related problems,'' social and family problems,^ and suicidality.^ Despite the prevalence of mental health problems, there is increasing evidence that OEF/OIF veterans underutilize mental health care services at the Department of Veterans Affairs (VA). A national study of OEF/OIF veterans enrolled in VA care found that fewer than 10% of those diagnosed with PTSD or depression received the recommended amount of mental health treatment within their first several months of care.' Dropout rates among OEF/OIF veterans are alarmingly high'""; one study at a VA PTSD clinic, for example, found that 68% of OEF/OIF veterans dropped out before completion.'" Research has also found that OEF/OIF veterans miss *South Texas Veterans Health Care System, Mental Health Outpatient Services, 5788 Eckhert Road 116A1, San Antonio, TX 78240. tDepartment of Psychiatry, University of Texas Health Science Center. 7400 Merton Minter Boulevard, San Antonio, TX 78229-4404. ifDepartment of Medicine, University of Texas Health Science Center, 7400 Merton Minter Boulevard, San Antonio, TX 78229-4404. §Department of Epidemiology and Biostatistics, University of Texas Health Science Center, 7400 Merton Minter Boulevard, San Antonio, TX 78229-4404. llPuget Sound Health Care System. Deployment Health Clinic (S-116), Seattle, WA 98108. ^Institute for Integration of Medicine and Science, PBRN Resource Center, University of Texas Health Science Center at San Antonio, 7400 Merton Minter Boulevard, San Antonio, TX 78229-4404. doi: 10.7205/MlLMED-D-13-00076
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more mental health appointments and dropout from PTSD treatment more often than Vietnam veterans." The younger age of OEF/OIF veterans relative to other veterans has been found to account for some of these differences in PTSD treatment utilization.'^'•^ It may also be that younger veterans are faced with competing titne demands related to their life stage and obligations to work and family. For example. Fontana and Rosenheck'"* found that OEF/OIF veterans were more likely to be employed than Gulf War or Vietnam veterans. Qualitative studies among OEF/OIF veterans have identified confiicting demands on time, such as juggling work schedules and mental health appointments, as barriers to care-seeking,'^"'^findingssupported by anecdotal reports from clinicians and researchers.'^ However, younger veterans may also hold more negative attitudes toward mental health treatment. Research among civilian men has found that younger men espouse more negative attitudes about mental health treatment relative to older men." Several studies conducted among OEF/OIF veterans have identified commonly endorsed perceptions of stigma and the need for self-reliance (i.e., the belief that "I ought to handle it on my own") as barriers to mental health care. 16.t8.19 These attitudes may be more pronounced among OEF/OIF veterans, as they may have more recently experienced the onset of mental health symptoms. Also, roughly 85% of OEF/OIF veterans are men. Because traditional tnasculine ideology has been associated with negative attitudes toward psychological help-seeking, particularly among younger men,'^ stigma against help-seeking among younger veterans may also be exacerbated by concerns about masculinity.'^ To better understand perceived barriers to care among OEF/OIF veterans compared with veterans of other eras, we
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assessed attitudes about therapy, patient-level logistical barriers (e.g., access to childcare and transportation), and institutional-level barriers to care such as after-hours appointment availability and receipt of appointment reminders. On the basis of previous studies of mental health care utilization, we hypothesized that OEF/OIF veterans would be more likely to endorse barriers to mental health care relative to their veteran counterparts of other eras.
METHOD Procedure A cross-sectional survey to assess attitudes toward therapy and perceived barriers to care was developed by the research team as part of the VA Mental Health Practice-Based Research Network. This specialty is supported by the Institute for the Integration of Medicine and Science at the University of Texas Health Science Center, San Antonio and an NIH Clinical Translational Science Award. Surveys were administered by front office staff to all patients seen for mental health appointments at nine VA mental health care outpatient clinics in the South Texas Veterans Health Care System. The survey was conducted over a 2-week period during the summer of 2010. Of the nine clinic sites, four were located in urban San Antonio, whereas the remaining five serve primarily rural populations in South Texas. All were general mental health clinics with the exception of one PTSD Clinical Team specializing in outpatient PTSD care. Participation was voluntary and the survey was anonymous. A total of 678 surveys were given to veterans with a 90% return rate, resulting in a final collection of 608 completed surveys. Measure Although previous measures of perceived barriers to mental health care have been developed and used among active duty OEF/OIF personnel to assess beliefs regarding mental health care seeking, these have focused on expected reactions by command or unit peers and may not apply to a veteran population separated from military service and living within civilian communities. Thus, we developed a one-page survey to identify possible barriers to mental health care based on clinical observations and the existing literature (see Table II for the list of questions). The survey was composed of two parts: (1) patient-level (4 items) and institutional-level (3 items) logistical reasons for not keeping any past VA mental health care appointments, such as employment confiicts or lack of after-hours care; and (2) attitudes about psychotherapy (9 items). Respondents rated each item using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). The survey also included questions related to patient demographic data, including age, sex, ethnicity, appointment type, and period of service.
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Data Analysis Because our respondents included relatively few veterans of the pre-Vietnam era, and because of the unique treatment needs of combat veterans vs. noncombat veterans, we limited the analysis to veterans who served in one of three mutually exclusive wartime service eras (Vietnam, Persian Gulf, and OEF/OIF). Eighty-one veterans reported serving during more than one era and were excluded from analysis. A total of 41 post-Vietnam, 6 World War II, and 4 Korean veterans were excluded from analyses. Nine who served between Korean and Vietnam wars were also excluded, as were 33 veterans who reported no service era. A total of 434 veterans remained for analyses. Descriptive statistics were used to analyze demographic variables. To assess internal consistency of the survey, Cronbach's a was computed separately for the logistical and attitudinal barriers sections. Summary statistics were cotnputed, including the mean and standard deviation (SD) of survey item response. Veterans were categorized into three mutually exclusive service era categories (Vietnam, Persian Gulf, and OEF/OIF). The questionnaire contained 16 items that measured agreement on a 5-point Likert scale, and both separate item-level and summative score statistical analyses were conducted. For each item, survey responses were assigned numeric values (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 - agree, 5 = strongly agree) and associations between Likert item response and veteran service era were examined using ordinal logistic regression. Agreement between item response and age was also evaluated among the subset of veterans who reported serving during OEF/OIF. Two summative scores were computed for each subject, a logistical barrier score and a psychotherapy attitudes score. Service era group scores were compared using the Kruskal-Wallis test with Sidak correction for multiple testing. Similar analyses were also conducted to compare response according to gender group. All statistical tests were performed at the 2-sided 0.05 level of statistical significance and all statistical analyses were conducted in SAS (Version 9.2; SAS Institute, Cary, North Carolina).
RESULTS Demographic characteristics of the 434 study subjects are shown in Table I. Men comprised 91% of respondents. Average age was 51 ± 14.4 years across the entire cohort and 32 + 8.2 for OEF/OIF, 43 ± 6.8 for Persian Gulf, and 62 ± 4.2 for Vietnam veterans. Among all participants, more than half were identified as Hispanic-White, and just under onethird as non-Hispanic White. Fifty-nine percent were veterans of the Vietnam War, and a quarter of the respondents served in OEF/OIF. Associations between service era and logistical barriers to care and attitudes toward psychotherapy are shown in Table II. OEF/OIF veterans were significantly more likely
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Perceived Treatment Barriers in OEFIOIF Veterans TABLE I.
Demographic Characteristics of Study Participants, All Service Eras {n = 434)
Characteristic Age (years) Mean (SD) Sex, n (%) Male Female Ethnicity, n {%) Non-Hispanic White Hispanic White African American Other Appointment Type, n (%) Eirst Eollow-up Hospital Discharge OEF/OIF, n (%) Persian Gulf, n {%) Vietnam, « (%)
51.2(14.4) 387(91.3) 37 (8.7) 130(31.6) 252(61.2) 16(3.9) 14 (3.4) 65 (17.2) 311(82.1) 3 (0.8)
113(26) 64(14.7) 257 (59.2)
Total numbers on which percentages are based vary because of missing demographic data.
to agree that appointment time conflicts with work relative to Vietnam era veterans (p < 0.001). OEF/OIF veterans were significantly more likely to report dishking to talk in groups, to feel that coming to treatment makes them weak, and to believe that treatment will make them go crazy, when compared to those who served during Vietnam or the Persian Gulf War. OEF/OIF veterans were also significantly more likely to agree that they should be able to handle problems on their own when compared to Vietnam {p < 0.001) and Persian Gulf {p 0.003). Finally, OEF/OIF veterans agreed significantly more often that previous therapy did not help (p = 0.002), and that their lives are too busy for treatment {p < 0.001) relative to Vietnam veterans. By contrast, Vietnam veterans were significantly more likely to believe their therapist really cares about them when compared to both OEF/OIF and Persian Gulf veterans (p = 0.002 andp = 0.03, respectively). Both the logistical barriers (Table II A) and psychotherapy attitudes (Table II B) survey sections had acceptable levels of internal consistency at 0.78 and 0.77, respectively. No differences in the logistical barriers score were found among veterans from any era; however, the psychotherapy attitudes mean score among OEF/OIF veterans (mean [SD] = 23.9 [5.9]) differed compared to both Vietnam (mean [SD] = 20.1 [5.4], p < 0.001) and Persian Gulf veterans (mean [SD]= 20.7 [5.1], p < 0.001). No significant differences between male and female veterans were found. We also examined agreement between item response and age in 113 OEF/OIF veterans. Unexpectedly, older OEF/OIF veterans were significantly more likely to agree that they cannot afford treatment (p = 0.02) and their lives are too busy for treatment {p = 0.02). No other survey items were significantly associated with age of OEF/OIF veterans.
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DISCUSSION Although previous work has examined differences in mental health care utilization among OEF/OIF veterans and other era veterans,'^ to our knowledge, this is the first study to examine perceived patient and institutional-level barriers and attitudes regarding mental health treatment across combat eras. OEF/ OIF veterans were more likely than Vietnam veterans to agree that work conflicts interfere with treatment and their lives are too busy for treatment, but across service eras there were no other differences observed for such logistical barriers. This is not surprising given that OEF/OIF veterans tend to be younger and still in the workforce, whereas Vietnam veterans tend to be at or near retirement age. Veterans did not differ by service era in their perceptions of other patient-level barriers to care, including not having reliable transportation, not being able to afford to come to treatment, or lack of childcare. Veterans also did not differ significantly on perceived institutional barriers to care, whether receiving reminders about appointments or a lack of after-hours or weekend appointments. Consistent with previous research,"^ current findings suggest that negative treatment attitudes may be more prominent than logistical barriers in predicting treatment engagement among OEF/OIF veterans, particularly those already enrolled in VA care.'"^ OEF/OIF veterans in this study were more likely to endorse negative treatment-related attitudes than were veterans of other eras. OEF/OIF veterans were significantly more likely than both Gulf War and Vietnam veterans to believe that coming to treatment means they are weak, that they should be able to handle problems on their own, that treatment will make them "go crazy," and to report an aversion to talking in groups. OEF/OIF veterans also were more likely than Vietnam veterans to report having previously been to therapy that did not help. In contrast, Vietnam veterans were more likely to believe that their therapist cares about them than either Gulf War or OEF/OIF veterans. These findings may reflect the relative differences in experience with mental health services, as OEF/OIF veterans may have had fewer episodes of care than veterans of previous eras; veterans who have had more episodes of care may also have had greater opportunities for positive experiences with mental health providers. These differences between OFF/OIF and Vietnam veterans may also reflect the fact that more recent veterans are closer to their military service and may retain a more powerful connection to stoic mihtary norms and values, which may in turn impact treatment attitudes.'" However, within the cohort of OEF/OIF veterans, older veterans were tnore likely than younger veterans to endorse barriers related to cost and time commitments. This pattern may reflect that older OEF/OIF veterans are more likely to be working full time or have family commitments that provide less flexibility to attend mental health sessions. This is consistent with our clinical impressions that younger OEF/OIF veterans are more often employed part-time, living with parents, and/or are attending college and may not have the same
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Perceived Treatment Barriers in OEEIOIF Veterans TABLE N.
Survey Item Response and Service Era Among 434 Veterans Vietnam
A. Logistical Barriers I Do Not Receive a Reminder N Mean (SD) Median [Q1,Q3] There Are No Appointments After Hours N Mean (SD) Median [Q1,Q3] There Are No Appointments on Weekends N Mean (SD) Median [Q1,Q3] I Do Not Have Reliable Transportation N Mean (SD) Median [Q1,Q3] Appointment Time Conflicts With My Work"-*** N Mean (SD) Median [Q1,Q3] I Do Not Have Childcare for Appointments N Mean (SD) Median [Q1,Q3] I Cannot Afford to Come N Mean (SD) Median [Q1,Q3] Logistical Barriers Score'' N Mean (SD) Median [Q1,Q3] Min, Max B. Psychotherapy Attitudes 1 Believe My Therapist Really Cares About Me"'**-'''* N Mean (SD) Median [QI,Q3] I Do Not Like to Talk in Groups"*'** N Mean (SD) Median [Q1,Q3] This Treatment Will Make Me Go Crazy"'***-'-*** N Mean (SD) Median [Q1,Q3] Coming to Treatment Means I Am Weak"-***-'^-** N Mean (SD) Median [Q1,Q3] This Treatment Will Make My Symptoms Better N Mean (SD) Median [Q1,Q3] I Should Be Able to Handle My Problems on My Own"***-''-** N Mean (SD) Median [Q1,Q3]
Persian Gulf
OEF/OIF
Total
242 2.3 (1.4) 2 [1,3]
63 2.4(1.4) 2 [1,4]
109 2.1 (1.4) 1 [1,3]
414 2.2(1.4) 2 [1,3]
223 2.5 (1.5) 3 [1,4]
63 2.8(1.6) 3 [1,4]
109 2.8(1.4) 3 [1,4]
395 2.6(1.5) 3 [1,4]
225 2.7(1.5) 3 [1,4]
63 2.8(1.6) 3 [1,4]
110 2.9(1.5) 3 [1,4]
398 2.8(1.5) 3 [1,4]
235 2(1.3) 2 [1,3]
63 2(1.3) 1 [1,3]
111 1.8(1.2) 1 [1,2]
409 2(1.3) 1 [1,3]
222 1.8(1.1) 1 [1,2]
61 2.2(1.5) 2 [1,3]
109 2.3 (1.3) 2 [1,3]
392 2(1.2) 1 [1,3]
219 1.8(1.1) 1 [1,3]
61 1.6(1.1) 1 [1,2]
108 1.9(1.2) 1 [1,3]
388 1.8(1.1) 1 [1,2]
223 1.9(1.1) 1 [1,3]
60 1.9(1.2) 1 [1,3]
107 1.9(1.1) 1 [1,3]
390 1.9(1.1) 1 [1,3]
196 14.7 (6) 14 [9.5,19] 7,31
58 15.5 (5.6) 15 [11,20] 7,26
102 15.5 (5.9) 15.5 [11,20] 7,29
356 15 (5.9) 15 [10,20] 7,31
241 4.2(1) 4 [4,5]
60 3.9(1) 4 [3,5]
107 3.9(1) 4 [3,5]
408 4(1) 4 [3,5]
241 3.4(1.4) 4 [2,5]
61 3.2(1.3) 3 [2,4]
110 3.8(1.1) 4 [3,5]
412 3.4(1.3) 4 [3,5]
234 2(1.1) 2 [1,3]
61 1.9(0.9) 2 [1,3]
109 2.4(1) 3 [2,3]
404 2.1(1) 2 [1,3]
242 2.1 (1.2) 2 [1,3]
59 1.9(0.9) 2 [1,2]
110 2.6(1.2) 2 [2,3]
411 2.2(1.2) 2 [1,3]
238 3.6(1.1) 4 [3,4]
58 3.6 (0.9) 4 [3,4]
110 3.6 (0.8) 4 [3,4]
406 3.6(1) 4 [3,4]
241 2.5 (1.3) 2 [1,3]
60 2.5(1.1) 2.5 [2,3]
110 3.1(1.1) 3 [2,4]
411 2.6(1.2) 3 [2,4] (continued)
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Perceived Treatment Barriers in OEFIOIF Veterans TABLE II.
Continued Vietnam
This Treatment Takes Too Much Time N Mean (SD) Median [Q1,Q3] I Have Been to Therapy Before and It Did Not Help"'** N Mean (SD) Median [Q1,Q3] My Life Is Too Busy for Treatment"*** N Mean (SD) Median [Q1,Q3] Psychotherapy Attitudes Score****" N Mean (SD) Median [Q1,Q3] Min, Max
Persian Gulf
OEF/OIF
236 2.1(1) 2 [1,3]
60 2.2 (0.9) 2 [1.5,3]
107 2.4(1.1) 2 [2,3]
403 2.2(1) 2 [1,3]
236 2.3(1.1) 2 [1,3]
59 2.4(1.1) 2 [2,3]
109 2.6(1.2) 3 [2,3]
404 2.4(1.1) 2 [1,3]
231 1.7(0.9) 2 [1,2]
60 2 (0.8) 2 [1,3]
106 2.3(1) 2 [1,3]
397 1.9(0.9) 2 [1,3]
196 20.1 (5.4) 20 [15,24] 9,37
56 20.7(5.1) 21 [18.5,24] 9,31
98 23.9 (5.9) 24 [20,28] 12,37
350 21.3 (5.8) 21 [17,25] 9,37
Total
Individual Likert item analysis: p Value logistic regression tests association between service era category and ordinal item response (5 = strongly agree to I = strongly disagree). *p < 0.05; **p < 0.01; ***p < 0.001. "Vietnam vs. OEF/OEF. *Vietnam vs. Persian Gulf 'Persian Gulf vs. OEF/OIF. Likert scale summative score analysis: p value Kmskal-Wallis test with Sidak correction. ****p < 0.001. ''Cronbach's a = 0.78. ""Cronbach's a = 0.77.
family demands relative to older OEF/OIF veterans. However, we did not assess family structure or work/student status and future research should specifically examine these factors in relationship to perceived barriers and attitudes toward mental health services. Research conducted among civilian men has long suggested that norms for masculine behavior can impact attitudes toward help-seeking.^""^^ A number of authors have observed the similarities between stigma related to help-seeking and masculinity norms within the military, which place heavy emphasis on self-reliance and stoicism in the face of distress.^'^"^^ Women have an increasing presence in military and combat operations and recent years have seen an accompanying increase in postdeployment mental health concerns among female veterans,"^^ leading to an unprecedented focus on their mental health care needs and treatment-seeking. We found similar treatment attitudes between male and female veterans in this study. Although our sample of female veterans was small (9%), it may be that military norms for self-reliance influence women veterans' use of mental health services as they do men's."^ Future research efforts should specifically examine the influence of traditional gender norms and/or stoic beliefs in association with help-seeking among both men and women veterans.
Limitations There were several limitations of the current study. First, the study used a convenience sample of veterans receiving mental health outpatient care in VA settings, which does not address the perceived barriers to care of those who elect not to seek care or to seek care outside the VA system. However, because perceived barriers exist among those receiving care, and treatment adherence and consistency vary in this popula-
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tion,' these data provide important insight into factors affecting treatment-seeking among this population of veterans. Second, the study used post hoc nonrandomized methods, which makes it impossible to draw definitive conclusions about the differences found between OEF/OIF veterans and veterans of other eras. Third, the study used cross-sectional data, upon which it is difficult to make causal inferences. Fourth, the study used a measure that has not been previously validated, although our items are largely consistent with those used in similar surveys.'^'^^ Fifth, we did not assess branch of service or active duty vs. National Guard/Reserve capacity, and treatment attitudes may vary according to these variables. Sixth, data on respondents' actual treatment utilization were not available, making it impossible to assess associations between reported treatment attitudes/perceived barriers and actual treatment adherence. Seventh, small numbers of veterans in agreement with some survey items led to imprecise measures of association, which suggest caution regarding interpretation of statistical results. Lastly, because ethnicity or cultural background may influence attitudes toward treatment and our subjects mostly identified as Hispanic, results may not generalize to other veteran populations.
Future Research In light of the large numbers of OEF/OIF veterans failing to engage in needed mental health treatment, a growing number of studies have focused on factors associated with treatment engagement and/or treatment retention.'^''^'''^ Future work in this area should aim to develop a more nuanced understanding of how demographic factors such as age and gender impact treatment-related attitudes and behaviors among veterans. Scholars have suggested that attitudinal barriers to mental health care among OEF/OIF veterans could
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potentially be addressed with motivational interviewing and cognitive behavioral therapy. '^'^** On the basis of the findings presented here, we believe such efforts might further benefit from directly challenging negative beliefs about psychological help-seeking informed by traditional gender norms. \2 Moreover, we believe that such efforts may have relevance for fernale veterans as well; the cultural expectation for emotional restriction is pervasive across military settings, and likely extends to female service members. Although additional research will be required to assess the effectiveness of such interventions in improving treatment adherence among both rnale and female veterans, findings underscore the potential benefits of outreach and education regarding mental health treatment to address OEF/OIF veterans' negative perceptions of treatment. ACKNOWLEDGMENT This project was supported by the Institute for the Integration of Medicine and Science at the University of Texas Health Science Center, San Antonio, and an National Institutes of Health Clinical Translational Science Award (CTSA).
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A Survey of Perceived Barriers and Attitudes Toward Mental Health Care Among OEF/OIF Veterans at VA Outpatient Mental Health Clinics Hector A. Garcia, PsyD*t; Erin P. Finiey, PhD, MPH*ft; Norma Ketchum, MS§; Matthew Jakupcak, PhDJI; Aibana Dassori, MD*t; Stephanie C. Reyes, BAJj ABSTRACT Objective: In an effort to improve our understanding of perceived treatment barriers among veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) relative to other era veterans, the current study examined veteran attitudes and beliefs about mental health treatment and treatment-seeking, and perceived patient and institutionlevel logistical barriers to care. Method: A survey was conducted among 434 Combat veterans seeking care in nine Veterans Affairs mental health care outpatient clinics. Results: When compared to Vietnam and Gulf War veterans, OEF/OIF veterans were significantly more likely to endorse negative treatment attitudes as possible barriers to care. OEF/OIF veterans were also more likely than Vietnam veterans to endorse conflicting work demands as a potential barrier, although this was the only logistical barrier for which OEF/OIF veterans' responses differed significantly from those of veterans of other eras. Among OEF/OIF veterans, older veterans were more likely than younger veterans to endorse barriers related to cost and time commitments. Conclusions: These findings suggest an important role for outreach and engagement strategies that address attitudinal barriers to treatment utilization among veteran populations.
INTRODUCTION Since September 11, 2001, upwards of two million U.S. veterans have served in support of Operations Enduring and Iraqi Freedom (OEF/OIF).' In this growing population of veterans, studies examining the mental health impact of combat deployment have identified significant rates of post-traumatic stress disorder (PTSD),^""^ depression,"' alcohol-related problems,'' social and family problems,^ and suicidality.^ Despite the prevalence of mental health problems, there is increasing evidence that OEF/OIF veterans underutilize mental health care services at the Department of Veterans Affairs (VA). A national study of OEF/OIF veterans enrolled in VA care found that fewer than 10% of those diagnosed with PTSD or depression received the recommended amount of mental health treatment within their first several months of care.' Dropout rates among OEF/OIF veterans are alarmingly high'""; one study at a VA PTSD clinic, for example, found that 68% of OEF/OIF veterans dropped out before completion.'" Research has also found that OEF/OIF veterans miss *South Texas Veterans Health Care System, Mental Health Outpatient Services, 5788 Eckhert Road 116A1, San Antonio, TX 78240. tDepartment of Psychiatry, University of Texas Health Science Center. 7400 Merton Minter Boulevard, San Antonio, TX 78229-4404. ifDepartment of Medicine, University of Texas Health Science Center, 7400 Merton Minter Boulevard, San Antonio, TX 78229-4404. §Department of Epidemiology and Biostatistics, University of Texas Health Science Center, 7400 Merton Minter Boulevard, San Antonio, TX 78229-4404. llPuget Sound Health Care System. Deployment Health Clinic (S-116), Seattle, WA 98108. ^Institute for Integration of Medicine and Science, PBRN Resource Center, University of Texas Health Science Center at San Antonio, 7400 Merton Minter Boulevard, San Antonio, TX 78229-4404. doi: 10.7205/MlLMED-D-13-00076
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more mental health appointments and dropout from PTSD treatment more often than Vietnam veterans." The younger age of OEF/OIF veterans relative to other veterans has been found to account for some of these differences in PTSD treatment utilization.'^'•^ It may also be that younger veterans are faced with competing titne demands related to their life stage and obligations to work and family. For example. Fontana and Rosenheck'"* found that OEF/OIF veterans were more likely to be employed than Gulf War or Vietnam veterans. Qualitative studies among OEF/OIF veterans have identified confiicting demands on time, such as juggling work schedules and mental health appointments, as barriers to care-seeking,'^"'^findingssupported by anecdotal reports from clinicians and researchers.'^ However, younger veterans may also hold more negative attitudes toward mental health treatment. Research among civilian men has found that younger men espouse more negative attitudes about mental health treatment relative to older men." Several studies conducted among OEF/OIF veterans have identified commonly endorsed perceptions of stigma and the need for self-reliance (i.e., the belief that "I ought to handle it on my own") as barriers to mental health care. 16.t8.19 These attitudes may be more pronounced among OEF/OIF veterans, as they may have more recently experienced the onset of mental health symptoms. Also, roughly 85% of OEF/OIF veterans are men. Because traditional tnasculine ideology has been associated with negative attitudes toward psychological help-seeking, particularly among younger men,'^ stigma against help-seeking among younger veterans may also be exacerbated by concerns about masculinity.'^ To better understand perceived barriers to care among OEF/OIF veterans compared with veterans of other eras, we
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assessed attitudes about therapy, patient-level logistical barriers (e.g., access to childcare and transportation), and institutional-level barriers to care such as after-hours appointment availability and receipt of appointment reminders. On the basis of previous studies of mental health care utilization, we hypothesized that OEF/OIF veterans would be more likely to endorse barriers to mental health care relative to their veteran counterparts of other eras.
METHOD Procedure A cross-sectional survey to assess attitudes toward therapy and perceived barriers to care was developed by the research team as part of the VA Mental Health Practice-Based Research Network. This specialty is supported by the Institute for the Integration of Medicine and Science at the University of Texas Health Science Center, San Antonio and an NIH Clinical Translational Science Award. Surveys were administered by front office staff to all patients seen for mental health appointments at nine VA mental health care outpatient clinics in the South Texas Veterans Health Care System. The survey was conducted over a 2-week period during the summer of 2010. Of the nine clinic sites, four were located in urban San Antonio, whereas the remaining five serve primarily rural populations in South Texas. All were general mental health clinics with the exception of one PTSD Clinical Team specializing in outpatient PTSD care. Participation was voluntary and the survey was anonymous. A total of 678 surveys were given to veterans with a 90% return rate, resulting in a final collection of 608 completed surveys. Measure Although previous measures of perceived barriers to mental health care have been developed and used among active duty OEF/OIF personnel to assess beliefs regarding mental health care seeking, these have focused on expected reactions by command or unit peers and may not apply to a veteran population separated from military service and living within civilian communities. Thus, we developed a one-page survey to identify possible barriers to mental health care based on clinical observations and the existing literature (see Table II for the list of questions). The survey was composed of two parts: (1) patient-level (4 items) and institutional-level (3 items) logistical reasons for not keeping any past VA mental health care appointments, such as employment confiicts or lack of after-hours care; and (2) attitudes about psychotherapy (9 items). Respondents rated each item using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). The survey also included questions related to patient demographic data, including age, sex, ethnicity, appointment type, and period of service.
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Data Analysis Because our respondents included relatively few veterans of the pre-Vietnam era, and because of the unique treatment needs of combat veterans vs. noncombat veterans, we limited the analysis to veterans who served in one of three mutually exclusive wartime service eras (Vietnam, Persian Gulf, and OEF/OIF). Eighty-one veterans reported serving during more than one era and were excluded from analysis. A total of 41 post-Vietnam, 6 World War II, and 4 Korean veterans were excluded from analyses. Nine who served between Korean and Vietnam wars were also excluded, as were 33 veterans who reported no service era. A total of 434 veterans remained for analyses. Descriptive statistics were used to analyze demographic variables. To assess internal consistency of the survey, Cronbach's a was computed separately for the logistical and attitudinal barriers sections. Summary statistics were cotnputed, including the mean and standard deviation (SD) of survey item response. Veterans were categorized into three mutually exclusive service era categories (Vietnam, Persian Gulf, and OEF/OIF). The questionnaire contained 16 items that measured agreement on a 5-point Likert scale, and both separate item-level and summative score statistical analyses were conducted. For each item, survey responses were assigned numeric values (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 - agree, 5 = strongly agree) and associations between Likert item response and veteran service era were examined using ordinal logistic regression. Agreement between item response and age was also evaluated among the subset of veterans who reported serving during OEF/OIF. Two summative scores were computed for each subject, a logistical barrier score and a psychotherapy attitudes score. Service era group scores were compared using the Kruskal-Wallis test with Sidak correction for multiple testing. Similar analyses were also conducted to compare response according to gender group. All statistical tests were performed at the 2-sided 0.05 level of statistical significance and all statistical analyses were conducted in SAS (Version 9.2; SAS Institute, Cary, North Carolina).
RESULTS Demographic characteristics of the 434 study subjects are shown in Table I. Men comprised 91% of respondents. Average age was 51 ± 14.4 years across the entire cohort and 32 + 8.2 for OEF/OIF, 43 ± 6.8 for Persian Gulf, and 62 ± 4.2 for Vietnam veterans. Among all participants, more than half were identified as Hispanic-White, and just under onethird as non-Hispanic White. Fifty-nine percent were veterans of the Vietnam War, and a quarter of the respondents served in OEF/OIF. Associations between service era and logistical barriers to care and attitudes toward psychotherapy are shown in Table II. OEF/OIF veterans were significantly more likely
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Perceived Treatment Barriers in OEFIOIF Veterans TABLE I.
Demographic Characteristics of Study Participants, All Service Eras {n = 434)
Characteristic Age (years) Mean (SD) Sex, n (%) Male Female Ethnicity, n {%) Non-Hispanic White Hispanic White African American Other Appointment Type, n (%) Eirst Eollow-up Hospital Discharge OEF/OIF, n (%) Persian Gulf, n {%) Vietnam, « (%)
51.2(14.4) 387(91.3) 37 (8.7) 130(31.6) 252(61.2) 16(3.9) 14 (3.4) 65 (17.2) 311(82.1) 3 (0.8)
113(26) 64(14.7) 257 (59.2)
Total numbers on which percentages are based vary because of missing demographic data.
to agree that appointment time conflicts with work relative to Vietnam era veterans (p < 0.001). OEF/OIF veterans were significantly more likely to report dishking to talk in groups, to feel that coming to treatment makes them weak, and to believe that treatment will make them go crazy, when compared to those who served during Vietnam or the Persian Gulf War. OEF/OIF veterans were also significantly more likely to agree that they should be able to handle problems on their own when compared to Vietnam {p < 0.001) and Persian Gulf {p 0.003). Finally, OEF/OIF veterans agreed significantly more often that previous therapy did not help (p = 0.002), and that their lives are too busy for treatment {p < 0.001) relative to Vietnam veterans. By contrast, Vietnam veterans were significantly more likely to believe their therapist really cares about them when compared to both OEF/OIF and Persian Gulf veterans (p = 0.002 andp = 0.03, respectively). Both the logistical barriers (Table II A) and psychotherapy attitudes (Table II B) survey sections had acceptable levels of internal consistency at 0.78 and 0.77, respectively. No differences in the logistical barriers score were found among veterans from any era; however, the psychotherapy attitudes mean score among OEF/OIF veterans (mean [SD] = 23.9 [5.9]) differed compared to both Vietnam (mean [SD] = 20.1 [5.4], p < 0.001) and Persian Gulf veterans (mean [SD]= 20.7 [5.1], p < 0.001). No significant differences between male and female veterans were found. We also examined agreement between item response and age in 113 OEF/OIF veterans. Unexpectedly, older OEF/OIF veterans were significantly more likely to agree that they cannot afford treatment (p = 0.02) and their lives are too busy for treatment {p = 0.02). No other survey items were significantly associated with age of OEF/OIF veterans.
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DISCUSSION Although previous work has examined differences in mental health care utilization among OEF/OIF veterans and other era veterans,'^ to our knowledge, this is the first study to examine perceived patient and institutional-level barriers and attitudes regarding mental health treatment across combat eras. OEF/ OIF veterans were more likely than Vietnam veterans to agree that work conflicts interfere with treatment and their lives are too busy for treatment, but across service eras there were no other differences observed for such logistical barriers. This is not surprising given that OEF/OIF veterans tend to be younger and still in the workforce, whereas Vietnam veterans tend to be at or near retirement age. Veterans did not differ by service era in their perceptions of other patient-level barriers to care, including not having reliable transportation, not being able to afford to come to treatment, or lack of childcare. Veterans also did not differ significantly on perceived institutional barriers to care, whether receiving reminders about appointments or a lack of after-hours or weekend appointments. Consistent with previous research,"^ current findings suggest that negative treatment attitudes may be more prominent than logistical barriers in predicting treatment engagement among OEF/OIF veterans, particularly those already enrolled in VA care.'"^ OEF/OIF veterans in this study were more likely to endorse negative treatment-related attitudes than were veterans of other eras. OEF/OIF veterans were significantly more likely than both Gulf War and Vietnam veterans to believe that coming to treatment means they are weak, that they should be able to handle problems on their own, that treatment will make them "go crazy," and to report an aversion to talking in groups. OEF/OIF veterans also were more likely than Vietnam veterans to report having previously been to therapy that did not help. In contrast, Vietnam veterans were more likely to believe that their therapist cares about them than either Gulf War or OEF/OIF veterans. These findings may reflect the relative differences in experience with mental health services, as OEF/OIF veterans may have had fewer episodes of care than veterans of previous eras; veterans who have had more episodes of care may also have had greater opportunities for positive experiences with mental health providers. These differences between OFF/OIF and Vietnam veterans may also reflect the fact that more recent veterans are closer to their military service and may retain a more powerful connection to stoic mihtary norms and values, which may in turn impact treatment attitudes.'" However, within the cohort of OEF/OIF veterans, older veterans were tnore likely than younger veterans to endorse barriers related to cost and time commitments. This pattern may reflect that older OEF/OIF veterans are more likely to be working full time or have family commitments that provide less flexibility to attend mental health sessions. This is consistent with our clinical impressions that younger OEF/OIF veterans are more often employed part-time, living with parents, and/or are attending college and may not have the same
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Perceived Treatment Barriers in OEEIOIF Veterans TABLE N.
Survey Item Response and Service Era Among 434 Veterans Vietnam
A. Logistical Barriers I Do Not Receive a Reminder N Mean (SD) Median [Q1,Q3] There Are No Appointments After Hours N Mean (SD) Median [Q1,Q3] There Are No Appointments on Weekends N Mean (SD) Median [Q1,Q3] I Do Not Have Reliable Transportation N Mean (SD) Median [Q1,Q3] Appointment Time Conflicts With My Work"-*** N Mean (SD) Median [Q1,Q3] I Do Not Have Childcare for Appointments N Mean (SD) Median [Q1,Q3] I Cannot Afford to Come N Mean (SD) Median [Q1,Q3] Logistical Barriers Score'' N Mean (SD) Median [Q1,Q3] Min, Max B. Psychotherapy Attitudes 1 Believe My Therapist Really Cares About Me"'**-'''* N Mean (SD) Median [QI,Q3] I Do Not Like to Talk in Groups"*'** N Mean (SD) Median [Q1,Q3] This Treatment Will Make Me Go Crazy"'***-'-*** N Mean (SD) Median [Q1,Q3] Coming to Treatment Means I Am Weak"-***-'^-** N Mean (SD) Median [Q1,Q3] This Treatment Will Make My Symptoms Better N Mean (SD) Median [Q1,Q3] I Should Be Able to Handle My Problems on My Own"***-''-** N Mean (SD) Median [Q1,Q3]
Persian Gulf
OEF/OIF
Total
242 2.3 (1.4) 2 [1,3]
63 2.4(1.4) 2 [1,4]
109 2.1 (1.4) 1 [1,3]
414 2.2(1.4) 2 [1,3]
223 2.5 (1.5) 3 [1,4]
63 2.8(1.6) 3 [1,4]
109 2.8(1.4) 3 [1,4]
395 2.6(1.5) 3 [1,4]
225 2.7(1.5) 3 [1,4]
63 2.8(1.6) 3 [1,4]
110 2.9(1.5) 3 [1,4]
398 2.8(1.5) 3 [1,4]
235 2(1.3) 2 [1,3]
63 2(1.3) 1 [1,3]
111 1.8(1.2) 1 [1,2]
409 2(1.3) 1 [1,3]
222 1.8(1.1) 1 [1,2]
61 2.2(1.5) 2 [1,3]
109 2.3 (1.3) 2 [1,3]
392 2(1.2) 1 [1,3]
219 1.8(1.1) 1 [1,3]
61 1.6(1.1) 1 [1,2]
108 1.9(1.2) 1 [1,3]
388 1.8(1.1) 1 [1,2]
223 1.9(1.1) 1 [1,3]
60 1.9(1.2) 1 [1,3]
107 1.9(1.1) 1 [1,3]
390 1.9(1.1) 1 [1,3]
196 14.7 (6) 14 [9.5,19] 7,31
58 15.5 (5.6) 15 [11,20] 7,26
102 15.5 (5.9) 15.5 [11,20] 7,29
356 15 (5.9) 15 [10,20] 7,31
241 4.2(1) 4 [4,5]
60 3.9(1) 4 [3,5]
107 3.9(1) 4 [3,5]
408 4(1) 4 [3,5]
241 3.4(1.4) 4 [2,5]
61 3.2(1.3) 3 [2,4]
110 3.8(1.1) 4 [3,5]
412 3.4(1.3) 4 [3,5]
234 2(1.1) 2 [1,3]
61 1.9(0.9) 2 [1,3]
109 2.4(1) 3 [2,3]
404 2.1(1) 2 [1,3]
242 2.1 (1.2) 2 [1,3]
59 1.9(0.9) 2 [1,2]
110 2.6(1.2) 2 [2,3]
411 2.2(1.2) 2 [1,3]
238 3.6(1.1) 4 [3,4]
58 3.6 (0.9) 4 [3,4]
110 3.6 (0.8) 4 [3,4]
406 3.6(1) 4 [3,4]
241 2.5 (1.3) 2 [1,3]
60 2.5(1.1) 2.5 [2,3]
110 3.1(1.1) 3 [2,4]
411 2.6(1.2) 3 [2,4] (continued)
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Perceived Treatment Barriers in OEFIOIF Veterans TABLE II.
Continued Vietnam
This Treatment Takes Too Much Time N Mean (SD) Median [Q1,Q3] I Have Been to Therapy Before and It Did Not Help"'** N Mean (SD) Median [Q1,Q3] My Life Is Too Busy for Treatment"*** N Mean (SD) Median [Q1,Q3] Psychotherapy Attitudes Score****" N Mean (SD) Median [Q1,Q3] Min, Max
Persian Gulf
OEF/OIF
236 2.1(1) 2 [1,3]
60 2.2 (0.9) 2 [1.5,3]
107 2.4(1.1) 2 [2,3]
403 2.2(1) 2 [1,3]
236 2.3(1.1) 2 [1,3]
59 2.4(1.1) 2 [2,3]
109 2.6(1.2) 3 [2,3]
404 2.4(1.1) 2 [1,3]
231 1.7(0.9) 2 [1,2]
60 2 (0.8) 2 [1,3]
106 2.3(1) 2 [1,3]
397 1.9(0.9) 2 [1,3]
196 20.1 (5.4) 20 [15,24] 9,37
56 20.7(5.1) 21 [18.5,24] 9,31
98 23.9 (5.9) 24 [20,28] 12,37
350 21.3 (5.8) 21 [17,25] 9,37
Total
Individual Likert item analysis: p Value logistic regression tests association between service era category and ordinal item response (5 = strongly agree to I = strongly disagree). *p < 0.05; **p < 0.01; ***p < 0.001. "Vietnam vs. OEF/OEF. *Vietnam vs. Persian Gulf 'Persian Gulf vs. OEF/OIF. Likert scale summative score analysis: p value Kmskal-Wallis test with Sidak correction. ****p < 0.001. ''Cronbach's a = 0.78. ""Cronbach's a = 0.77.
family demands relative to older OEF/OIF veterans. However, we did not assess family structure or work/student status and future research should specifically examine these factors in relationship to perceived barriers and attitudes toward mental health services. Research conducted among civilian men has long suggested that norms for masculine behavior can impact attitudes toward help-seeking.^""^^ A number of authors have observed the similarities between stigma related to help-seeking and masculinity norms within the military, which place heavy emphasis on self-reliance and stoicism in the face of distress.^'^"^^ Women have an increasing presence in military and combat operations and recent years have seen an accompanying increase in postdeployment mental health concerns among female veterans,"^^ leading to an unprecedented focus on their mental health care needs and treatment-seeking. We found similar treatment attitudes between male and female veterans in this study. Although our sample of female veterans was small (9%), it may be that military norms for self-reliance influence women veterans' use of mental health services as they do men's."^ Future research efforts should specifically examine the influence of traditional gender norms and/or stoic beliefs in association with help-seeking among both men and women veterans.
Limitations There were several limitations of the current study. First, the study used a convenience sample of veterans receiving mental health outpatient care in VA settings, which does not address the perceived barriers to care of those who elect not to seek care or to seek care outside the VA system. However, because perceived barriers exist among those receiving care, and treatment adherence and consistency vary in this popula-
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tion,' these data provide important insight into factors affecting treatment-seeking among this population of veterans. Second, the study used post hoc nonrandomized methods, which makes it impossible to draw definitive conclusions about the differences found between OEF/OIF veterans and veterans of other eras. Third, the study used cross-sectional data, upon which it is difficult to make causal inferences. Fourth, the study used a measure that has not been previously validated, although our items are largely consistent with those used in similar surveys.'^'^^ Fifth, we did not assess branch of service or active duty vs. National Guard/Reserve capacity, and treatment attitudes may vary according to these variables. Sixth, data on respondents' actual treatment utilization were not available, making it impossible to assess associations between reported treatment attitudes/perceived barriers and actual treatment adherence. Seventh, small numbers of veterans in agreement with some survey items led to imprecise measures of association, which suggest caution regarding interpretation of statistical results. Lastly, because ethnicity or cultural background may influence attitudes toward treatment and our subjects mostly identified as Hispanic, results may not generalize to other veteran populations.
Future Research In light of the large numbers of OEF/OIF veterans failing to engage in needed mental health treatment, a growing number of studies have focused on factors associated with treatment engagement and/or treatment retention.'^''^'''^ Future work in this area should aim to develop a more nuanced understanding of how demographic factors such as age and gender impact treatment-related attitudes and behaviors among veterans. Scholars have suggested that attitudinal barriers to mental health care among OEF/OIF veterans could
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potentially be addressed with motivational interviewing and cognitive behavioral therapy. '^'^** On the basis of the findings presented here, we believe such efforts might further benefit from directly challenging negative beliefs about psychological help-seeking informed by traditional gender norms. \2 Moreover, we believe that such efforts may have relevance for fernale veterans as well; the cultural expectation for emotional restriction is pervasive across military settings, and likely extends to female service members. Although additional research will be required to assess the effectiveness of such interventions in improving treatment adherence among both rnale and female veterans, findings underscore the potential benefits of outreach and education regarding mental health treatment to address OEF/OIF veterans' negative perceptions of treatment. ACKNOWLEDGMENT This project was supported by the Institute for the Integration of Medicine and Science at the University of Texas Health Science Center, San Antonio, and an National Institutes of Health Clinical Translational Science Award (CTSA).
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