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Title: Military Personnel Who Seek Health and Mental Health Services Outside the Military.
Author: Waitzkin H, Cruz M, Shuey B, Smithers D, Muncy L, Noble M.
Journal: Mil Med; 2018 May 01; 183(5-6):e232-e240. PubMed ID: 29415229.
Abstract:
BACKGROUND: Although research conducted within the military has assessed the health and mental health problems of military personnel, little information exists about personnel who seek care outside the military. The purpose of this study is to clarify the personal characteristics, mental health diagnoses, and experiences of active duty U.S. military personnel who sought civilian sector services due to unmet needs for care. MATERIALS AND METHODS: This prospective, multi-method study included 233 clients, based in the United States, Afghanistan, South Korea, and Germany, who obtained care between 2013 and 2016 from a nationwide network of volunteer civilian practitioners. A hotline organized by faith-based and peace organizations received calls from clients and referred them to the network when the clients described unmet needs for physical or mental health services. Intake and follow-up interviews at 2 wk and 2 mo after intake captured demographic characteristics, mental health diagnoses, and reasons for seeking civilian rather than military care. Non-parametric bootstrap regression analyses identified predictors of psychiatric disorders, suicidality, and absence without leave (AWOL). Qualitative analyses of clients' narratives clarified their experiences and reasons for seeking care. The research protocol has been reviewed and approved annually by the Institutional Review Board at the University of New Mexico. RESULTS: Depression (72%), post-traumatic stress disorder (62%), alcohol use disorder (27%), and panic disorder (25%) were the most common diagnoses. Forty-eight percent of clients reported suicidal ideation. Twenty percent were absence without leave. Combat trauma predicted post-traumatic stress disorder (odds ratio [OR] = 8.84, 95% confidence interval [CI] 1.66, 47.12, p = 0.01) and absence without leave (OR = x3.85, 95% CI 1.14, 12.94, p = 0.03). Non-combat trauma predicted panic disorder (OR = 3.64, 95% CI 1.29, 10.23, p = 0.01). Geographical region was associated with generalized anxiety disorder (OR 0.70, 95% CI 0.49, 0.99, p = 0.05). Significant predictors were not found for major depression, alcohol use disorder, or suicidal ideation. Clients' narrative themes included fear of reprisal for seeking services, mistrust of command, insufficient and unresponsive services, cost as a barrier to care, deception in recruitment, voluntary enlistment remorse, guilt about actual or potential killing of combatants or non-combatant civilians, preexisting mental health disorders, family and household challenges that contributed to distress, and military sexual trauma. CONCLUSIONS: Our work clarified substantial unmet needs for services among active duty military personnel, the limitations of programs based in the military sector, and the potential value of civilian sector services that are not linked to military goals. We and our institutional review board opted against using a control group that would create ethical problems stemming from the denial of needed services. For future research, an evaluative strategy that can assess the impact of civilian services and that reconciles ethical concerns with study design remains a challenge. Due to inherent contradictions in the roles of military professionals, especially the double agency that makes professionals responsible to both clients and the military command, the policy alternative of providing services for military personnel in the civilian sector warrants serious consideration, as do preventive strategies such as non-military alternatives to conflict resolution.

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