Factors Affecting Help Seeking for Mental Health Problems After ...

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Factors Affecting Help Seeking for Mental Health Problems After Deployment to Iraq and Afghanistan Lindsey A. Hines, M.Sc. Laura Goodwin, Ph.D. Margaret Jones, B.A. Lisa Hull, M.Sc.

Simon Wessely, F.R.C.Psych., F.Med.Sci. Nicola T. Fear, D.Phil. (Oxon.) Roberto J. Rona, Ph.D., F.F.P.H.

Objective: This study assessed the prevalence of general medical problems, stress or emotional problems, and alcohol problems reported by members of the armed forces of the United Kingdom after deployment in Iraq or Afghanistan. The study also identified types of help seeking and factors associated with help seeking. Methods: A total of 4,725 military personnel who were deployed to Iraq, Afghanistan, or both were asked about health problems attributable to the deployment and whether they had sought help for them. Data were collected through postal surveys between 2007 and 2009. Service and sociodemographic covariates and measures of current mental health, alcohol misuse, and functional impairment were included in the analyses. Results: Of the 19% who reported stress or emotional problems, 42% sought help, most commonly medical help (29%). Of the 6% who reported alcohol problems, 31% sought help, most commonly medical help (17%). Medical help seeking for stress or emotional problems was associated with being female, holding a lower rank, having functional impairment, and meeting criteria for two or more mental health problems. Being divorced or separated was positively associated with nonmedical help seeking for stress or emotional problems. Help seeking for alcohol problems was associated with current mental disorders. Conclusions: Medical help seeking for stress or emotional problems was uncommon and was related to meeting criteria for two or more mental health problems. Commissioned officers were reluctant to seek medical help for stress or emotional problems. Help seeking for alcohol problems increased if personnel were experiencing additional mental health problems. (Psychiatric Services in Advance, September 16, 2013; doi: 10.1176/appi.ps.004972012)

I

ndividuals with mental health problems often avoid seeking professional help (1), a pattern that can be exacerbated within the military by concerns about career prospects and perceptions of stigma (2–4). Combat troops and reservists

have poorer mental health after deployment, which may affect their lives, their families’ lives, and their occupational effectiveness (5,6). Therefore, it is important to establish if personnel seek help for health problems after deployment.

Ms. Hines, Dr. Goodwin, Ms. Jones, Ms. Hull, Professor Wessely, and Professor Rona are with the King’s Centre for Military Health Research, King’s College London (e-mail: [email protected]). Dr. Fear is with the Academic Centre for Defence Mental Health at King’s College London.

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In the United Kingdom, use of mental health care services by the military remains stable (7,8), but the data do not reflect how many personnel experience problems without seeking help (9). Research from both the United States and the United Kingdom has provided a consensus that only a minority of military personnel with mental health problems seek medical care (2,10,11) A previous report from the United Kingdom showed that service members have a relatively accurate perception of their mental health problems (10) but that only 18.5% received treatment from general medical sources, and most help was received from informal sources (10,12). Vogt (4) has identified a gap in the literature on research into factors that contribute to low help seeking among military personnel experiencing a mental health problem. In this article, we seek to fill this gap by describing helpseeking patterns within the military. Specifically, we aimed to investigate the prevalence of self-reported health problems among military personnel after deployment and to identify sources of help used by military personnel and factors associated with help-seeking behavior.

Methods Study population The sample was drawn from phase 2 of a cohort study conducted by the King’s Centre for Military Health Research (6,13). Phase 1 consisted of 1

a randomly selected sample of personnel serving in the first phase of the Iraq war (January–June 2003). The sample included two groups: individuals deployed in the first phase of the Iraq war and individuals who served at that time but were not deployed to Iraq. Data were collected between June 2004 and March 2006 through a self-report questionnaire. Reservists and personnel who had left the military were included. Questionnaires were completed by 10,272 of the 17,499 phase 1 personnel contacted, for a response rate of 59% (13). Phase 2, from which the study sample was taken, consisted of 9,395 individuals who participated in phase 1 and who consented to follow-up. The sample also included 1,825 regular military personnel and reservists deployed to Afghanistan between April 2006 and April 2007 and a replenishment group of 6,628 regular personnel and reservists, who joined and trained between April 2003 and April 2007 and who were added to ensure that the age and rank distribution remained representative of deployed members of the United Kingdom armed forces. A total of 9,990 regular personnel and reservists completed questionnaires between November 2007 and September 2009, for a response rate of 56% (6). Completion of the questionnaire at phase 2 was not associated with mental health status (6). Study sample A total of 4,986 participants had been deployed to Iraq, Afghanistan, or both, and 4,725 (95%) responded to an item in the questionnaire asking about general medical problems, stress or emotional problems, and alcohol problems resulting from their last deployment to Iraq or Afghanistan. A total of 2,561 individuals were deployed most recently to Iraq, and 2,164 were deployed most recently to Afghanistan. For the 970 who had served in both Iraq and Afghanistan and who provided information on their health after both deployments, only data from the most recent deployment were used. The final sample comprised 4,246 regular military personnel and 479 reservists. Full details of the study were given to the 2

participants, who then provided consent for future contact and access to medical and resettlement records. The study was reviewed and received ethical approval from the King’s College Hospital (London) research ethics committee and from the Ministry of Defence’s research ethics committee. Outcome measures Participants who reported experiencing general medical problems, stress or emotional problems, or alcohol problems as a result of their last deployment were asked whether they had sought professional help from a general medical practitioner or medical officer, who provide both general medical and mental health care, along with referrals to specialist health providers, such as a psychologist or psychiatrist; a specialist, such as a hospital doctor, psychiatrist, community psychiatric nurse, or counselor; or a nonmedical professional, such as a military chaplain, welfare officer, or social worker (in the United Kingdom, a position that mainly involves helping individuals solve health, housing, or social welfare issues). Participants could report more than one problem and more than one source of help for each problem. Help seeking comprised three categories. Medical help included seeking help from a general medical practitioner, medical officer, or specialist, even if additional help was sought from nonmedical professionals. Nonmedical help included seeking help only from nonmedical professionals. A third group comprised those who did not seek any help. Both medical and nonmedical help seeking for alcohol problems were combined into one variable, given that the numbers reporting each type of help were small. Consequently, the variable for help seeking for alcohol problems consisted of two categories: seeking any help for alcohol problems— including help from a general practitioner, medical officer, specialist, and nonmedical professional—and not seeking help. Explanatory measures Mental health status in the few weeks prior to completing the questionnaire

was also measured. Posttraumatic stress disorder (PTSD) was assessed by using the 17-item PTSD Checklist– Civilian Version (PCL-C), with a score of 50 or more indicating probable PTSD (14). The General Health Questionnaire212 (GHQ-12) was used to identify a case of psychological distress (score of $4) (15). A 53-item Multiple Physical Symptom (MPS) scale, including symptoms of the Hopkins Symptom Checklist (16) and symptoms reported in studies of Gulf War veterans, was used to assess somatic symptoms that often co-occur with psychological problems but that are infrequently associated with physical problems unrelated to mental illness; having 18 or more symptoms indicates a case of somatic symptoms (13). To investigate whether help seeking was affected by number of mental health problems, we constructed a composite measure by combining the PCL-C, the GHQ-12, and the MPS. The measure identified persons who met case criteria for no, one, or two or more mental health problems (PTSD, psychological distress, or multiple physical symptoms). The World Health Organization Alcohol Use Disorders Identification Test (AUDIT) was used to assess alcohol problems (17). The AUDIT score is split into three categories: scores below 16 indicate no serious alcohol misuse, scores of 16–19 indicate cases of serious alcohol misuse, and scores of 20 or more indicate cases of serious alcohol misuse that are likely to include functional impairment (18). The impact of ill health on functioning was assessed by a self-rating of the extent to which general medical or emotional problems interfered with normal social activities, which could range from not at all to extremely. A binary variable was constructed, with responses of “quite a bit” or “extremely” indicating functional impairment and responses of “moderately,” “slightly,” or “not at all” indicating no functional impairment. Data analysis Multinomial regression was used to investigate factors (demographic, military, social functioning, and self-reported current health) associated with help seeking for stress or emotional problems PSYCHIATRIC SERVICES IN ADVANCE

resulting from deployment. No help seeking, nonmedical help seeking, and medical help seeking were the dependent variables. Multinomial odds ratios (MORs) with 95% confidence intervals (CIs) are reported. Adjusted analyses were conducted by using variables identified by the unadjusted analysis and in the literature as possible confounders (age, sex, marital status, type of engagement, and rank). Logistic regression was used to investigate factors (demographic, military, social functioning, and selfreported current health) associated with any help seeking (medical or nonmedical) for alcohol problems. The analyses were adjusted for demographic variables (age, sex, marital status, engagement type, and rank). Odds ratios (ORs) with CIs are reported for both analyses. Given that previous research within the military indicates that there is less recognition of alcohol problems than of other mental health problems (10) and that help seeking for these problems may be affected by severity of the problem, we report, by AUDIT score (,16, 16–19, and $20), the proportion of those seeking help for alcohol problems. Weights were created to account for sample fractions, given that the analyses combined three independent randomly selected samples, and for the lower response rate at phase 2 among younger service personnel, members of lower ranks, and males (6). All analyses were conducted by using the statistical software package Stata, version 10. Unweighted frequencies, weighted percentages, MORs, and ORs are reported.

Table 1

Characteristics of 4,725 military personnel after deployment to Iraq or Afghanistana Characteristic

Totalb

Age 18–24 25–29 30–34 35–39 $40 Male Marital status Single Married or long-term relationship Former relationship Service Naval services Army Royal Air Force Engagement Regular Reservist Role Combat Noncombat Current service Last deployment Iraq Afghanistan Rank Commissioned officer Other Any health problem General medical Stress or emotional Alcohol Number of health problems 0 1 2 3 Met criteria for mental health problemd PCL-C GHQ AUDIT score 16–19 $20 MPS

4,725

a b

Results Sample characteristics A majority of respondents were male, married or in a long-term relationship, and regular military personnel. The weighted mean6SD age was 32.767.6. For 61%, the last deployment was to Iraq, and for 39%, the last deployment was to Afghanistan (Table 1). Altogether, 25% reported any health problems; 19%, stress or an emotional problem; 8%, a general medical problem, and 6%, an alcohol problem (Table 1). A total of 152 (4%) reported a general medical problem PSYCHIATRIC SERVICES IN ADVANCE

c d

4,725 4,698

N

%c

977 1,128 906 863 851 4,315

17 25 20 20 17 92

906 3,503 289

17 76 7

452 3,367 906

9 73 18

4,246 479

94 6

1,108 3,503 4,254

25 75 89

2,561 2,164

61 39

978 3,747 1,174 361 888 291

17 83 25 8 19 6

3,551 877 255 42

75 18 6 1

179 868

4 19

408 357 417

9 8 10

4,725

4,725 4,611 4,713 4,725 4,725 4,725 4,651 4,659 4,605 4,725

4,725

For those deployed to both Iraq and Afghanistan, the most recent deployment was used. Total personnel for whom information was available Percentages are weighted. The PTSD Checklist–Civilian Version (PCL-C) identifies posttraumatic stress disorder; the General Health Questionnaire (GHQ) identifies psychological distress; the Alcohol Use Disorders Identification Test (AUDIT) identifies serious alcohol misuse (score 16–19) and serious alcohol misuse with functional impairment (score $20); and the Multiple Physical Symptom (MPS) scale identifies a case of multiple physical symptoms.

and stress or an emotional problem. In addition, 47% (N=827) of those with a general medical problem reported stress or an emotional problem, but only 18% (N=309) of the group with stress or an emotional problem reported a general medical problem.

Help-seeking behaviors Of the 888 service members reporting stress or an emotional problem, 42% reported seeking help, with medical help (29%) reported most commonly (Table 2). Thirty-one percent of those with alcohol problems reported seeking help, with medical help reported 3

Table 2

Prevalence of help seeking among 4,725 military personnel, by problem

a

General medical problem (N=361)

Stress or emotional problem (N=888)

Type of help

N

%

N

%

N

%

Medical Nonmedical Any

310 6 316

85 1 86

252 118 370

29 13 42

57 36 93

17 14 31

a

Percentages are weighted.

most commonly (17%). In contrast, 85% of those with a general medical problem reported seeking medical help. Factors associated with help-seeking behavior Adjusted analyses indicated that medical help seeking for stress or emotional problems was associated with being female (MOR=2.73), having current functional impairment (MOR= 3.22), meeting criteria for two or more mental health problems (MOR= 2.68), and an AUDIT score of 20 or more (MOR=1.79). The odds of seeking medical help were reduced for individuals of officer rank (MOR=.40) (Table 3). Nonmedical help seeking for stress or emotional problems was positively associated with being divorced or separated (MOR=2.25) and negatively associated with last deploying to Afghanistan (MOR=.53). There was an increasing trend in the association between seeking any help for alcohol problems and number of current mental health problems (Table 4). AUDIT score was not associated with help seeking for alcohol problems, and no other significant associations were found for help seeking for perceived alcohol problems (data available on request). Recognition of alcohol problems Forty-one percent of respondents scoring 20 or more on the AUDIT reported having an alcohol problem after deployment, compared with only 14% of those with an AUDIT score of 16–19 and 3% of those with a score below 16 (data not shown), indicating that most participants who recognized 4

Alcohol problem (N=291)

alcohol use as a problem had a very high AUDIT score.

Discussion Stress or emotional problems were the most commonly reported health problems after deployment and were reported more than twice as commonly as general medical or alcohol problems. Help seeking for stress or emotional problems and for alcohol problems was much lower than for general medical problems. Medical help seeking for stress or emotional problems was greater among those with two or more mental health problems and those with current functional impairment and was lower among commissioned officers. Help seeking for alcohol problems was associated with number of current mental health problems. Prevalence of help seeking Our study demonstrates the reluctance to seek medical help for stress or emotional problems or alcohol problems compared with the willingness to seek help for a general medical problem and confirms the findings of other reports (2,10,19–22). Given that health care is free in the United Kingdom, the ability to pay is not a barrier to treatment among activeduty personnel and veterans, but other barriers must be considered. Previous research has found that military populations have concerns about taking leave from work for treatment (3,23). However, only 15% of those reporting a general medical problem did not seek medical help, indicating that taking time off to attend a medical consultation is not an overriding concern. It may be the

case that personnel view general medical problems as having a more direct impact on their service preparedness and fitness, but research also suggests that they are concerned that seeking help for mental health problems could damage military careers (24) and cause others in the military to lose confidence in them (3). In addition, the low percentage seeking professional help for mental health problems may reflect a willingness to deal with the problems personally (25) and an unwillingness to admit help seeking. Reluctance to seek help for alcohol problems was compounded by low recognition of having a problem. Only 6% of participants reported an alcohol problem after deployment, whereas a report based on validated measures indicated that 13% of the military in the United Kingdom engage in alcohol misuse (6). In addition, no association was found between serious alcohol misuse and help seeking for alcohol problems. Instead, our study suggests that alcohol misuse was recognized as a problem if it was accompanied by other mental disorders or if the participant had an AUDIT score of 20 or more, a score associated with functional impairment (18). This is consistent with previous findings (10). Factors associated with help seeking The military mirrors the general population in that women are more likely to seek medical help (11,26–28), a pattern that is often attributed to social norms related to masculine identity (29). Within this sample, the military population differed from the general population in that age was not found to be associated with help seeking, possibly because of the relatively young age of active-duty personnel. Although the age distribution of our sample was comparable with that of the United Kingdom armed forces, the mean age of the sample was higher than the mean age in the U.S. military population, which is approximately 29 years (30). Participants who were no longer in a long-term relationship were more likely to seek nonmedical help for stress or an emotional problem than participants who were single or in PSYCHIATRIC SERVICES IN ADVANCE

PSYCHIATRIC SERVICES IN ADVANCE

5

61 53 45 58 50 56 68 55 63 57 60 63 38 58 62 49 65 59 43

383 94 37

449 69

422 96

262 256

325 181

449 63

364 70 65

258 152 94

54 40 22

86 16 14

99 17

83 33

70 48

93 25

102 16

12 16 14

13 14 14

13 15

14 13

15 10

13 16

14 12

12 16 20

13 12

%

1.00 1.49 1.78

1.00 1.01 1.23

1.00 1.82

1.00 .88

1.00 .58*

1.00 1.00

1.00 1.00

1.00 1.53 2.26*

1.00 1.37

MOR

.86–2.57 .92–3.44

.50–2.05 .58–2.59

.90–3.66

.52–1.50

.36 –.95

.53–1.86

.46–2.18

.81–2.90 1.03–4.95

.62–3.04

.98

95% CI

Univariable

1.00 1.50 1.72

1.00 .99 1.26

1.00 1.69

1.00 .90

1.00 .53**

1.00 1.06

1.00 1.02

1.00 1.51 2.25*

1.00 1.27

.71–1.36

MOR

Adjustedb

.87 –2.61 .88–3.37

.48–2.02 .57–2.75

.84–3.40

.51–1.59

.32 –.87

.55–2.05

.46–2.26

.77–2.97 1.02–4.98

.57–2.81

.98

95% CI

84 68 94

172 29 49

165 85

164 82

145 107

229 23

217 35

169 51 31

215 37

.67–1.43

N

Medical help (N=252)

23 25 43

28 23 37

24 47

29 27

30 26

30 17

28 38

27 31 35

27 49

32.267.8

%

1.00 1.17 2.81***

1.00 .76 1.57

1.00 3.16***

1.00 .86

1.00 .75

1.00 .46**

1.00 1.59

1.00 1.28 1.70

1.00 2.77***

1.04

MOR

.74–1.85 1.78–4.42

.44–1.33 .96–2.59

2.02–4.94

.58–1.26

.52–1.08

.25 –.82

.92–2.77

.81–2.04 .92–3.15

1.56–4.90

.82–1.33

95% CI

Univariable

1.00 1.22 2.68***

1.00 .87 1.79*

1.00 3.22***

1.00 1.03

1.00 .77

1.00 .40***

1.00 1.44

1.00 1.23 1.51

1.00 2.73***

1.19

MOR

Adjustedb

.76–1.96 1.67–4.28

.50–1.51 1.05–3.05

2.00–5.20

.68–1.56

.52–1.12

.21 –.75

.81–2.56

.76–1.99 .81–2.79

1.52–4.91

.90–1.57

95% CI

b

Percentages are weighted. Multinomial odds ratios (MORs) were adjusted for age, sex, marital status, engagement type, and rank. Age was a continuous variable and was rescaled by dividing by 10. c AUDIT, Alcohol Use Disorders Identification Test. Scores ,16 indicate no serious alcohol misuse; 16–19, serious alcohol misuse; and $20, serious alcohol misuse with probable functional impairment. d Mental health problems were identified by a composite cumulative measure reflecting the results of the PTSD Checklist–Civilian Version, the General Health Questionnaire, and the Multiple Physical Symptom scale. *p,.05, **p,.01, ***p,.005

a

105 13

60 40

477 41 81 22 15

31.967.5

32.067.3

N

Age Sex Male Female Marital status Married or long-term relationship Single Former relationship Engagement Regular Reserves Rank Other or noncommissioned officer Commissioned officer Last deployment Iraq Afghanistan Role Noncombat Combat Functional impairment No Yes AUDIT scorec ,16 16–19 $20 Mental health problemsd 0 1 $2

%

N

Factor

No help (N=518)

Nonmedical help (N=118)

Factors associated with help seeking among 888 military personnel who reported stress or emotional problems after deploymenta

Table 3

Table 4

Factors associated with help seeking among 291 military personnel with alcohol problemsa

Factor

Mental health problemsc 0 1 $2 AUDIT scored ,16 16–19 $20

Help seeking (N=93)

Univariable

Adjustedb

N

%

OR

95% CI

OR

95% CI

30 29 30

21 35 41

1.00 2.11* 2.73**

1.03–4.31 1.30–5.72

1.00 2.33* 2.70**

1.12–4.88 1.26–5.82

33 15 44

35 24 6

1.00 .57 .82

.24–1.34 .42–1.61

1.00 .51 .75

.21–1.23 .37–1.53

a

Percentages are weighted. Odds ratios (ORs) were adjusted for age, sex, marital status, engagement type, and rank. c Mental health problems were identified by a composite cumulative measure reflecting the results of the PTSD Checklist–Civilian Version, the General Health Questionnaire, and the Multiple Physical Symptom scale. d AUDIT, Alcohol Use Disorders Identification Test. Scores ,16 indicate no serious alcohol misuse; 16–19, serious alcohol misuse; and $20, serious alcohol misuse with probable functional impairment. *p,.05, **p,.01, ***p,.005 b

a relationship. Persons who are in or have previously been in a long-term relationship access mental health services more often (26), and encouragement from friends or family may help to overcome barriers to care (31). As indicated by previous research (2), we found that participants returning from Afghanistan reported seeking help less than those who deployed to Iraq, but we did not find an association between combat role and help-seeking behavior, as has been reported (22). There was also no association between engagement type and help seeking. Commissioned officers were less likely than other ranks to seek medical help for stress or an emotional problem. Personnel of higher rank are less likely to seek help for mental health problems (26,32), and the rate of mental health problems is lower among commissioned officers (33). However, our study went a step further by demonstrating that commissioned officers were less likely to seek medical help for stress or an emotional problem. This may be related to concerns about stigma and damage to their military career (34,35). It is not surprising that meeting criteria for two or more mental health problems was associated with medical help seeking, given that this is 6

consistent with previous research (11,16,26,32). Our study suggests that experiencing more than one mental health problem was a trigger to seeking medical help for both those who endorsed stress or an emotional problem and those with an alcohol problem. Our study adds to the literature by demonstrating that although meeting criteria for one mental health problem was not associated with seeking help, participants who met criteria for two or more mental health problems were more inclined to seek medical help. Our study is unique in demonstrating that functional impairment is associated with seeking medical rather than nonmedical help. Indeed, it was the factor most strongly associated with seeking medical help for stress or emotional problems, indicating that personnel commonly do not seek help until problems are severe. There are opposing views about the desirability of help seeking for mild psychological morbidity (27,36,37), and consideration should be given to the importance of treating less severe mental health problems within a military population. Strengths and weaknesses This was a large study based on a representative sample of the armed

forces of the United Kingdom and included a large number of covariates to assess factors affecting the use of health and welfare facilities. One limitation of this study was that the use of self-report may have led to underreporting or overreporting of help seeking. The findings for prevalence of health problems may have been affected by the study’s focus on problems resulting from deployment, given that some participants may not have acknowledged problems that they did not perceive to be deployment related. We were able to assess the association between reporting stress or emotional problems and alcohol problems after deployment and mental health at the time of questionnaire completion. Although nonparticipation was a possible source of potential bias, nonresponse in phase 2 among those who participated in phase 1 was unrelated to mental health status (6). Given that this study was based on a cross-sectional analysis, care should be taken to avoid interpreting associations as causal relationships. Implications The most striking finding is that a high percentage of military personnel reported stress or an emotional problem yet did not seek help. This was the case despite implementation by the armed forces of the United Kingdom of psychoeducational interventions that address deployment stress, depression, PTSD, alcohol use, relationship problems, and ways to cope with postdeployment problems (38) and the use of a trauma risk management tool (39). Given the association between help seeking and symptom severity, a proportion of those who self-reported stress or an emotional problem may have believed that the issue would be of short duration and that professional help would not be required. Commissioned officers may need to be targeted in relation to stress or emotional problems. Our study showed that officers who recognize stress or an emotional problem were less likely than other ranks to seek help. It is possible that commissioned officers do not take part in programs for coping with stress that are provided by the armed forces and that PSYCHIATRIC SERVICES IN ADVANCE

they may feel isolated because they are unwilling to share personal problems with their peer group. Conclusions Alcohol misuse is common in the United Kingdom armed forces but is not usually recognized as a problem, and few of those who recognize their problem seek help. Although stress or emotional problems were the most common health problem after deployment, help seeking for these problems was low. In addition, medical help seeking was less likely among those who met criteria for only one mental health problem and those who were less likely to have functional impairment, indicating lower severity of stress or emotional problems. It is unclear whether refraining from help seeking for less severe disorders was a response to the belief that the problem would be short lived or a balancing act between seeking help and concerns about the negative effects of help seeking on service members’ reputation and career prospects. Acknowledgments and disclosures This study was funded by the Ministry of Defence of the United Kingdom. Professor Wessely is honorary civilian consultant advisor in psychiatry to the British Army and a Trustee of Combat Stress. The authors report no competing interests.

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