Predictors of Barriers to Mental Health Treatment for Kosovo and Bosnia Peacekeepers: A Preliminary Report

Military Medicine, May 2006 by Maguen, Shira, Litz, Brett T

In this study, we assessed basic, physical, and mental health needs of peacekeepers; determined barriers to mental health treatment; and examined predictors of barriers to mental health care. Active duty peacekeepers were surveyed before and after their deployment to Kosovo (n = 203) concerning their stress symptoms and attitudes about seeking mental health care after peacekeeping. Sixty-five peacekeepers were evaluated before and after their peacekeeping deployment to Bosnia. Upon returning from their mission, between 5% and 9% of Kosovo and Bosnia peacekeepers reported needing help for anger or hostility, depression, or deployment-related stress. The most frequently endorsed barrier was concern about the personal cost of mental health care. Among Kosovo peacekeepers, pre- and postdeployment post-traumatic stress disorder symptoms were the most robust predictors of mental health treatment barriers. Peacekeepers report a number of treatment needs and barriers that could prevent them from receiving care. The soldiers most in need of services are also those who report the most barriers to care.

Introduction

The majority of individuals in the United States with posttraumatic stress disorder (PTSD)' do not seek or receive services for their condition because of other pressing priorities, a lack of availability and knowledge of treatment resources, income disparities, stigma, and shame.2 Veterans may be especially at risk for underusing mental health care. Veterans with chronic PTSD as a result of service in Vietnam, in particular, have underused mental health treatment services. For example, the National Vietnam Veterans Readjustment Study demonstrated that only 30% of male veterans and 42% of female veterans ever used any mental health services.3 Although the majority of Vietnam veterans are eligible for mental health services through the Veterans Affairs (VA) Healthcare Systems, VA mental health service utilization is significantly lower, with 8% of male and female Vietnam veterans using these services.3 Even among Vietnam theater veterans diagnosed with PTSD, only 20% of male veterans and 42% of female veterans ever used VA mental health services. These rates are comparable to those for veterans of Operation Enduring Freedom and Operation Iraqi Freedom.4 Similarly, Rosenheck et al.5 demonstrated that 38% of veterans who are chronically disabled with PTSD from all conflicts do not receive mental health care within the VA health care system. This is striking, given the vast resources devoted to the care of patients with PTSD in the VA system.

It appears that central mediators of mental health care seeking, especially when relatively low-cost treatment is readily available, are attitudes about the nature of psychotherapeutic processes and the meaning of seeking treatment. For example, individuals with elevated psychiatric symptoms who do not seek mental health treatment report barriers such as lack of confidence in care and fears of stigma.6 Attitudes about treatment are cited most frequently as barriers to care, and logistic characteristics such as cost, distance, and knowledge of where to seek services are reported less frequently.6,7 Studies also found that, contrary to what would be expected, individuals in the community who report greater PTSD symptoms are often less likely to seek treatment.8 In a cross-sectional survey comparing individuals with PTSD and control subjects, those with PTSD were more functionally impaired and disadvantaged socioeconomically but were receiving fewer mental health services.9

There are no known studies of barriers to mental health treatment among new veterans of modern peacekeeping operations. Given that the frequency of U.S. involvement in multinational peacekeeping operations has dramatically increased in the past 10 years, we sought to determine whether there are barriers to mental health care seeking among peacekeepers.

Since June 1999, the United States has contributed -5,300 soldiers to the NATO-led international force responsible for establishing security in Kosovo (Kosovo Force). The mission was sanctioned and mandated by the United Nations as a peaceenforcement operation. In Bosnia, there were -18,000 soldiers in the initial wave of NATO's implementation force, and U.S. military peacekeepers were deployed to Bosnia after the signing of the Dayton peace accord, which was maintained throughout the mission. The objectives of both peacekeeping operations were to establish and to maintain security, to monitor and to enforce compliance with the agreements that ended the conflict, and to assist in rebuilding infrastructure. The majority of soldiers cope exceptionally well with the challenges of peacekeeping in missions where peace has already been well established. However, peace-enforcement operations, such as in Kosovo and Bosnia, are associated with greater risk for psychopathology because of more-frequent exposure to potentially traumatizing events and greater internal conflict.10 As a result of these more stressful duties, soldiers may need to seek mental health treatment for help in coping with problems such as stress related to deployment, PTSD, depression, anger/hostility, or substance abuse problems.11