Systematic review

BMJ Mil Health: first published as 10.1136/bmjmilitary-2021-001903 on 12 July 2021. Downloaded from http://militaryhealth.bmj.com/ on January 9, 2023 by guest. Protected by copyright.
Veteran help-­seeking behaviour for mental health
issues: a systematic review
Rebecca Randles  ‍ ‍, A Finnegan  ‍ ‍

Westminster Centre for ABSTRACT

Research in Veterans, University Key messages
Introduction  Serving military personnel and veterans
of Chester Faculty of Health and
Social Care, Chester, UK have been identified to have a high prevalence of mental
► Serving military personnel and veterans have a
health disorders. Despite this, only a significantly small
high prevalence of mental disorders, but only a
Correspondence to number seek mental healthcare. With the UK beginning
significantly small number seek help.
A Finnegan, University of to invest further support to the armed forces community,
► Barriers to help-­seeking behaviour included
Chester, Chester, UK; ​a.​ identification of barriers and facilitators of help-­seeking
finnegan@​chester.​ac.​uk stigma, military culture of stoicism and self-­
behaviour is needed. reliance as well as deployment characteristics
Received 31 May 2021 Methods  Corresponding literature search was conducted such as combat exposure.
Accepted 10 June 2021 in PsycINFO, PsycArticles, Medline, Web of Science and ► Facilitators of help-­seeking included dispelling
Published Online First EBSCO. Articles which discussed barriers and facilitators
12 July 2021 the stigma and myths surrounding help-­
of seeking help for mental health concerns in the veteran seeking and mental health treatment as well as
population were included. Those which discussed serving involvement of other veterans.
personnel or physical problems were not included within ► Further research is needed within the UK
this review. A total of 26 papers were analysed. context with the lack of longitudinal evidence
Results  A number of barriers and facilitators of help-­ on the barriers and facilitators as well as the
seeking for a mental health issue within the veteran popu- limited research on female veterans.
lation were identified. Barriers included stigma, military
culture of stoicism and self-­reliance, as well as deployment
characteristics of combat exposure and different warzone
primary healthcare and MH services attributing to
deployments. Health service difficulties such as access and
successful support and treatment for veterans.13
lack of understanding by civilian staff were also identi-
Primary healthcare within the UK is expected to
fied. Facilitators to help combat these barriers included
record and support their veterans through prioriti-
a campaign to dispel the stigma, including involvement
sation and veteran-­specific services.5 6 14 Research
of veterans and training of military personnel, as well as
has shown as little as 8.7% of veterans have been
more accessibility and understanding from healthcare
identified, with many healthcare staff and veterans
staff.
not seeing the benefit in recording a veteran’s
Conclusions  While some barriers and facilitators have
status, leading to barriers among veterans who are
been identified, much of this research has been conducted
seeking support.15 More recently, the UK NHS has
within the USA and on male veterans and lacks longitu- introduced Op COURAGE, which aims to support
dinal evidence. Further research is needed within the the AFC by providing bespoke MH and well-­being
context of other nations and female veterans and to services.5–7 There is UK research regarding help-­
further indicate the facilitators of help-­seeking among seeking behaviour in the armed forces12 and the use
veterans. of social prescribing activities such as archaeology16
to help facilitate access to appropriate support.
However, the focus of this article is the identifi-
cation of barriers and facilitators of help-­seeking
INTRODUCTION behaviour and the beneficial approaches to under-
Serving military personnel and veterans have been stand how the military veteran community can be
identified to have a high prevalence of mental better supported.
health (MH) disorders.1 2 Despite this, only a
significantly small number seek MH care.3 4 With METHODOLOGY
the UK beginning to invest further support to the Literature search strategy
armed forces community (AFC), identification of A rapid review of the literature was conducted over
barriers and facilitators of help-­seeking behaviour a period of three months. This review was guided
is needed.5–7 Help-­seeking behaviour is defined as by the Preferred Reporting Items for Systematic
© Author(s) (or their a planned behaviour of actively seeking help with
employer(s)) 2022. Re-­use Reviews and Meta-­ Analyses (PRISMA).17 Corre-
permitted under CC BY-­NC. No a healthcare professional due to changes in health.8 sponding literature searches wereconducted in
commercial re-­use. See rights Facilitators and barriers to help-­seeking behaviour the following databases: PsycINFO, PsycArti-
and permissions. Published in reference to MH difficulties have been frequently cles, Medline, Web of Science and EBSCO. These
by BMJ. researched in the literature.9–12 Certain MH disor- databases were selected due to the quality of their
To cite: Randles R, ders within the veteran community have been peer-­reviewed publications and their utilisation in
Finnegan A. BMJ Mil Health found to be associated with more substantial health previous literature review publications of a similar
2022;168:99–104. service utilisation, with collaboration between focus. Furthermore, the journal impact factors of
Randles R, Finnegan A. BMJ Mil Health 2022;168:99–104. doi:10.1136/bmjmilitary-2021-001903    99
 Systematic review

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is often used interchangeably with help-­ seeking. Therefore
Table 1  Search parameters of the literature review
should a publication fall in line with the meaning of help-­seeking
Search number Field Search words behaviour, this was also included despite using an alternative
S1 Title OR abstract Veteran OR ex-­forces OR ex-­military term. Publications which discussed serving personnel were not
S2 Title OR abstract Help Seeking OR Treatment Seeking OR included in the review, even if this was in conjunction with the
Help Seeking Behavi?r discussion of veterans. This is due to the focus of the review being
S3 – S1 AND S2 the help-­seeking behaviour of veterans. The authors acknowl-
S4 Subject Veteran OR ex-­forces OR ex-­military edge that MH disorders often originate from physical health
S5 Subject Help Seeking OR Treatment Seeking OR problems; however, the focus of this review was primarily help-­
Help Seeking Behavi?r seeking for MH disorders and physical problems were excluded.
S6 – S4 AND S5 The selection of the papers was conducted by the first author
Database search limits used and this is therefore a single-­screening review. Although there is
By language: English potential for selection bias in a single-­screening approach, due
By peer-­reviewed/academic journal type to the rapid nature of the review and the systematic approach
of selection using the PRISMA guidelines, this single-­screening
approach is more accepted.18 19 The second author was available
the BMJ Military Health and Military Medicine were searched to discuss the selections and confirm those for inclusion. Table 1
due to their focus and credibility in armed forces research. details the search of the literature review.
Databases were limited to those written in the English language
and published in peer-­reviewed/academic journals, with years
1990–2021 as inclusion criteria. Only two articles were included Procedure
before the year 2000 with the rationale of providing deployment The search consisted of the following stages:
contexts to help-­seeking behaviour. ► Initial search: search of keywords as defined in Table 1.
► Duplicate removal: duplicates across databases and journals
Inclusion and exclusion criteria were removed.
Articles that discussed veteran help-­seeking behaviour towards ► Title/abstract screening: title and abstract were screened to
MH services were included, specifically those that discussed look for relevance.
barriers and/or facilitators of help-­seeking behaviour. A meth- ► Paper screening: full publications were then screened to
odological consideration should be noted that treatment-­seeking check that there was discussion surrounding the barriers

Figure 1  PRISMA flow diagram of literature review publication selection. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-­
Analyses.
100 Randles R, Finnegan A. BMJ Mil Health 2022;168:99–104. doi:10.1136/bmjmilitary-2021-001903
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and/or facilitators of veteran help-­seeking behaviour for MH often concerned with the stigmatising labels that are associated
problems. Figure 1 outlines these stages in more detail. with MH issues, such as being viewed as ‘crazy’, with as many
as 44% of veterans agreeing that accessing treatment would
RESULTS make them appear weak.21 32 Despite this, only 12% of veterans
Numerous studies demonstrated that veterans were able to recog- agreed that they themselves would view others as weak if they
nise that they had current MH issues, with as many as 76.6% sought treatment.21 Public stigma was particularly prominent in
reporting problems.20 In the USA, research has revealed 72% of veterans within the homeless population who believed that, due
veterans screening positive for a MH disorder, suggesting that to their homeless status, they would be more likely to be treated
veterans are accurately able to recognise a MH problem.21 In poorly, which hindered their motivation to receive help for any
contrast, there is evidence that veterans were generally poor at MH concerns.33 In addition, veterans also felt that they were
identifying symptoms of mental distress.22 Despite this recog- stigmatised by the general public due to any MH problem that
nition and prevalence of mental disorders, small numbers of has been induced by their service, as they believed that some
veterans reported accessing MH services.23–25 However, there civilians view their service as an ‘adventurous vacation’, with
were several factors that increased the likelihood of accessing some even viewing them as murderers.38
MH services, such as symptom severity, support networks and However, Cerully et al37 found a lack of longitudinal data
being in crisis.26–28 for assessing the relationship between MH stigma, particularly
within the veteran population. Data consisted of a small number
of studies which found no relationship between self-­stigma and
Barriers to help-seeking behaviour
treatment-­seeking. However, self-­stigma was found to be posi-
Barriers to help-­ seeking behaviour were highly homogenous
tively related to treatment attrition. This suggests that much
across the literature, with similar themes appearing despite
of the literature we currently have regarding stigma and help-­
research coming from several different countries. However,
seeking behaviour in the veteran population employed a cross-­
there was a transatlantic dialogue from the USA that did not
sectional and self-­reported method of data collection, which
translate to other countries, and that is a barrier of affordability
holds the limitations of being less objective and makes it difficult
of healthcare.29–32 This was of particular concern to the homeless
to make causal inferences. Furthermore, there is lack of research
veteran population, despite their lack of income entitling them
regarding stigma among female veterans, although it has been
to free healthcare.33 Within some countries, these concerns were
found that female veterans have significantly lower levels of
not present due to the free healthcare that is available to the
internalised stigma than male veterans.40
entire population. However, the NHS was seen as having long
waiting lists and difficulties of access.22 Furthermore, a veteran
study in Denmark stated that there was a lack of veteran-­specific Military culture, identity and characteristics
services.24 Therefore, there are barriers to veterans’ help-­seeking Military culture and identity prescribes to the idea that soldiers
behaviour which are nation-­specific. should be heavily self-­reliant, with a frequently cited emphasis
on stoicism.27 29 31 41 This identity means that veterans often cite
Stigma the military culture of prioritising fulfilment of a mission over
Several types of stigma were described among the literature as personal discomfort as well as of sickness being regarded as a
barriers to help-­seeking: internalised stigma, anticipated stigma sign of weakness.22 32 39 41 42 This sense of pride that veterans
and public stigma.23 27 34 35 Internalised stigma refers to veterans’ hold and their belief that admitting they need MH support
negative beliefs regarding MH problems and treatment-­seeking, would mean they were no longer a ‘hero’ suggest that veterans
such as feeling ashamed.34 36 Furthermore, there was also an do not seek help due to a sense of honour.25 38
internalised belief that seeking treatment would make veterans Female veterans are often overlooked in the literature,
appear ‘weak’.31 In addition, there were several negative stigma- potentially due to them being a smaller population within the
tising beliefs held by veterans in regard to MH, such as believing military. However, studies have indicated that female veterans
those with MH problems cannot be counted on or take care of report higher pressure to uphold the reputation of female
themselves.28 Internalised stigma suggests that veterans’ own service members, citing that women are often not taken seriously
negative beliefs regarding MH are a barrier to help-­ seeking within the military.40 43 Many female veterans have adopted
behaviour, as having these beliefs would impede on wanting the same attitudes as male veterans in not wanting to appear
to seek help for MH problems due to fear.22 29 34 36 However, weak.40 43 Subsequently, female veterans feel the need to ‘prove’
internalised stigma has, on occasions, been found to not be their strength with a sense of competitiveness towards their male
significantly associated with poor help-­seeking.28 37 This lack of counterparts, with one female veteran suggesting that men are
significant effect could be due to a veteran’s perceived need for in fact better at encouraging help-­seeking than women within
care, mediating the relationship between internalised stigma and the military.29 43 However, from a quantifiable data point, no
help-­seeking.35 gender differences were found, suggesting that help-­ seeking
Anticipated stigma refers to stigma that veterans would expect behaviours across both genders in military veterans were the
to receive from others.34 38 As many as 29.9% of veterans believed same,31 43 although there has been some research which suggests
that, if they had a MH problem, their friends and family would men have more negative beliefs towards MH than women.28
feel uncomfortable around them.28 Further literature reported However, these gender differences within the veteran popula-
that veterans’ lack of help-­seeking was due to fear of a MH tion are significantly under-­researched.
problem interfering with their career and career prospects.22 25 Help-­seeking behaviour may also be attributed to history
This would suggest that anticipated stigma from others may of operational deployments and unit characteristics particu-
hinder veterans from wanting to seek help for an MH condition larly when it comes to combat exposure.26 It has been found
due to fear of how others would perceive them. that every increase of 1 SD when measuring veterans’ combat
Public stigma refers to a belief that the general population exposure increased their likelihood of using a veteran service by
would perceive them as ‘damaged goods’.25 29 33 39 Veterans were 81%.26 This can be supported by a US study by Krill Williston
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et al,28 who found that veterans who served on active duty as a facilitator is supported by Williston et al,35 who reported
reported more negative beliefs about treatment-­ seeking than that veterans with higher MH literacy endorsed less negative
those who were in the national guard or reserves. In addition, beliefs about help-­seeking and that there was no relationship
when comparing veterans who deployed to different warzones, between literacy and actual utilisation of MH services.
veterans who were deployed to Operation Enduring Freedom Moreover, recommendations were made surrounding training
(OEF) or Operation Iraqi Freedom (OIF) were significantly those in leadership positions within the military.36 Some veterans
more likely to dislike talking in groups, feel that treatment makes believed that making MH educational sessions mandatory would
them appear weak and that previous attempts at treatment did help to facilitate help-­seeking behaviour, while others felt that
not help compared with veterans from the Vietnam War.31 This this would lead to a lack of engagement.36 Many agreed that
may also be due to combat exposure or the experiences on those the involvement of a veteran as a mentor would further facili-
particular deployments. Furthermore, painful self-­ conscious tate help-­seeking,36 and veterans perceived that seeing another
emotions, such as guilt and shame, were found to be significantly veteran seek help for their own MH concerns was a crucial
associated with emotional control and self-­reliance for veterans facilitator in dispelling the stigma and would often lead to them
who had been deployed to a warzone, suggesting that those who seeking help.22
had higher combat exposure may be more likely to attempt to
self-­treat any MH problems, likely due to military attitudes of
Health service facilitators and symptom severity
self-­reliance.27 44 Further Vietnam veteran research indicated that
Veterans who were able to recognise that they had a problem
veterans who did not want to be in the military or deploy did not
were more than seven and a half times more likely to be inter-
seek help for any veteran-­related issues.45 Therefore, this may
ested in receiving help.20 This suggests that recognition of a
also be the case for those who were recruited for national service
problem is a facilitator of help-­seeking behaviour.30 47 In addi-
in the UK or any other form of military conscription. In addi-
tion, the severity of the symptoms that a veteran is experiencing
tion, veterans from the OEF/OIF deployment had much greater
can also facilitate help-­seeking behaviour, with veterans often
perceptions that they would not fit into the US Department of
commenting that the problem would have to be ‘severe’ for them
Veterans Affairs, further highlighting that deployment and unit
to seek treatment.22 Research indicated that depression severity
characteristics have an effect on help-­seeking behaviour.46
is significantly positively correlated with MH treatment usage,
meaning that those with more severe depression were more likely
Access to health services to seek treatment.24 26 34 45 This symptom severity was also asso-
Help-­seeking behaviour appeared to be hindered by difficulties ciated with a veteran’s perceived need for care, where encour-
in access and usage of MH services. Accessibility was quite a agement from a veterans’ support network can increase the
prominent problem, with veterans discussing issues such as potential of a veteran to seek help.27 39 Furthermore, veterans’
transportation, lack of appointments available as well as staffing perceived need for care was usually due to no longer being able
issues.30 32 Veterans reported a dissatisfaction with their encour- to self-­manage the symptoms that they were experiencing.22 42
agement to seek help on leaving the military as well as with the This would suggest that veterans experiencing severe symptoms
services that were available, specifically for veterans.32 36 42 This regarding their MH would motivate them to seek support for
lack of US veteran-­specific services led to veterans believing that their MH concerns as they would also be more likely to recog-
the civilian healthcare providers would not understand what nise that there was a problem, particularly if they felt they were
they were going through and that it would be difficult to discuss no longer able to self-­manage their symptoms.
such problems with a stranger.22 30 36 This meant that veterans The accessibility of MH services was discussed as a potential
prioritised ‘basic needs’ over seeking MH treatment, such as facilitator of help-­seeking.27 30 32 36 Veterans revealed that MH
housing and employment.29 Further concerns regarding accessi- treatment would be more easily accessible if the first point of
bility can be found within the veteran homeless population, such contact could be a telephone call or via online communication,
as having no form of identification or a place where they can be as well as being more accessible outside of working hours, where
regularly contacted.33 veterans were likely to need additional support.27 36 This acces-
There were also concerns regarding privacy and secu- sibility was also facilitated when veterans held beliefs that were
rity.27 30 32 36 Some veterans reported distrust of the healthcare more treatment-­encouraging, such as believing getting help was
system and fearing what may be done with confidential informa- socially acceptable, that the opinions of other people did not
tion.30 32 36 In addition, veterans reported that services were non-­ matter, that treatment is helpful and that those who are encour-
responsive and ineffective and have limited resources to be able aging help-­seeking are trustworthy.30 42 In addition, veterans’
to deal with problems outside of business hours.27 30 The reasons views on how the MH services could be better conducted to
for holding this belief may be due to previous experiences with facilitate help-­seeking appeared to differ drastically, with some
the healthcare system, where some veterans have reported being emphasising the need for inperson contact and others believing
discharged when they were still in need of help.22 42 online services would be more ideal to combat the barrier of
fearing their confidential information would be shared as this
format would allow for anonymity.32 36 Furthermore, Vietnam
Facilitators of help-seeking behaviour
veterans reported wanting a more professional environment for
Barriers to help-­seeking behaviour were more heavily researched
when they receive treatment, with other veterans stating that
than that of the facilitators. However, the facilitators that
they did not feel comfortable discussing their MH in a hospital-­
were found were highly homogenous across the literature.
like environment.42 The facilitators and barriers to help-­seeking
Veterans believed that dispelling the stigma that currently
are provided diagrammatically in Figure 2.
exists surrounding MH would help to facilitate help-­ seeking
behaviour.36 Recommendations included an awareness campaign
that would normalise the help-­seeking process through the use CONCLUSIONS
of personal stories from other veterans as well as improving While research is available on veteran help-­seeking behaviour,
veteran awareness of available services.22 36 Enhanced awareness currently this remains heavily focused on the USA, with female
102 Randles R, Finnegan A. BMJ Mil Health 2022;168:99–104. doi:10.1136/bmjmilitary-2021-001903
 Systematic review

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Figure 2  Identified barriers and facilitators of veterans’ help-­seeking behaviour.

veterans and longitudinal data also being under-­ researched. of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
However, barriers and facilitators of help-­seeking behaviour can responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
still be identified and potentially used to better support veterans of the translations (including but not limited to local regulations, clinical guidelines,
in a UK context. Barriers identified were that of stigma, mili- terminology, drug names and drug dosages), and is not responsible for any error
tary culture of stoicism, unit characteristics such as warzone and/or omissions arising from translation and adaptation or otherwise.
deployment, as well as service difficulties such as access and Open access  This is an open access article distributed in accordance with the
understanding. Facilitators were found to be suppressing the Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
stigma through awareness campaigns and using military leaders permits others to distribute, remix, adapt, build upon this work non-­commercially,
and other veterans to promote help-­seeking as well as those in and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
crisis being more likely to seek help. Identifying the reasons for is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
poor help-­seeking behaviour and where veterans have sought
support is part of the evaluation of the Armed Forces Covenant ORCID iDs
Fund Trust’s Serious Stress programme,48 with results due later Rebecca Randles http://orcid.org/0000-0002-7401-5817
A Finnegan http://orcid.org/0000-0002-2189-4926
in 2021. However, further research is needed to better under-
stand how the AFC can be better supported to seek help for
MH-­related problems. REFERENCES
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