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PSYCHIATRIC SERVICES ps.psychiatryonline.org February 2011 Vol. 62 No. 2 135

Military personnel are at highrisk of exposure to poten-tially traumatic events and,

as a consequence, may be particularly susceptible to mental health prob-lems. Research findings based on themost recent cohort of veterans re-

turning from Operation Iraqi Free-dom (OIF) and Operation EnduringFreedom (OEF) suggest that veter-ans may experience a range of mentalhealth problems, including, especial-ly, posttraumatic stress disorder

(PTSD), depression, and generalizedanxiety (1–5). In one recent study, ap-proximately one-third of returningOEF-OIF soldiers experienced majordepression, PTSD, suicidal ideation,interpersonal conflict, or aggressiveideation approximately six months af-

ter returning from deployment (4).Despite extensive efforts on the part

of both military and Veterans HealthAdministration (VHA) leadership toenhance access to mental health serv-ices for military personnel and veter-

ans, research findings indicate thatmany returning war veterans do notseek out needed services. For exam-ple, in one study of OEF-OIF veteransidentified as having serious mentalhealth problems, only between 23%and 40% reported having sought men-tal health care, and less than half indi-cated an interest in receiving mentalhealth care (1). In a more recent study,less than half (42%) of OIF military personnel referred for mental healthcare after deployment received follow-up care, and over one-third (39%) of those referred for mental health caresix months later did not pursue follow-up care (4). Thus it appears that theuse of mental health services amongmilitary personnel and veterans doesnot parallel expected prevalence and

need, underscoring the importance of efforts to identify factors that influ-ence mental health service use withinthese populations.

One factor that may be especially salient with respect to understanding why veterans do or do not seek outneeded mental health services is a vet-eran’s beliefs about mental health andmental health treatment. In particular,concerns about public stigma, as re-flected in the extent to which an individual believes that he or she will be

stigmatized by others for having amental health problem, as well as per-sonal beliefs about mental illness andmental health treatment, may have im-plications for service use. This concep-tualization draws from research on at-titudes toward mental health careamong the general public by Corriganand colleagues (6,7), who have focusedon both public stigma, defined as thegeneral society’s reaction to people with mental illness, and self-stigma,

Mental Health–Related Beliefs asa Barrier to Service Use for MilitaryPersonnel and Veterans: A Review Daw ne Vogt, Ph.D.

Dr. Vogt is affiliated with the National Center for PTSD, U.S. Department of Veterans Af- fairs Boston Healthcare System, 150 South Huntington Ave. (116B-5), Boston, MA 02116(e-mail: [email protected]). She is also affiliated with the Division of Psychiatry,Boston University School of Medicine.

Objective: Although military personnel are at high risk of mental healthproblems, research findings indicate that many military personnel andveterans do not seek needed mental health care. Thus it is critical toidentify factors that interfere with the use of mental health services for this population, and where possible, intervene to reduce barriers tocare. The overarching goal of this review was to examine what is known with regard to concerns about public stigma and personal beliefs aboutmental illness and mental health treatment as potential barriers to serv-ice use in military and veteran populations and to provide recommen-dations for future research on this topic. Methods: Fifteen empirical ar-ticles on mental health beliefs and service use were identified via a re-view of the military and veteran literature included in PsycINFO andPubMed databases. Results: Although results suggest that mental healthbeliefs may be an important predictor of service use for this population,several gaps were identified in the current literature. Limitations in-clude a lack of attention to the association between mental health be-liefs and service use, a limited focus on personal beliefs about mental ill-ness and mental health treatment, and the application of measures of mental health beliefs with questionable or undocumented psychometricproperties. Conclusions: Studies that attend to these important issues

and that examine mental health beliefs in the broader context within which decisions about seeking health care are made can be used to besttarget resources to engage military personnel and veterans in healthcare. ( Psychiatric Services 62:135–142, 2011)

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reflected in the internalization of neg-ative beliefs about mental illness.Findings based on research with thegeneral public indicate that concernsabout public stigma may be a powerfuldeterrent to service use. For example,“concerns about what others wouldthink” was identified as a key barrier tothe use of treatment in the NationalComorbidity Survey (8), and 24% of

adults who reported unmet need formental health care identified stigmaavoidance as a barrier to care in anoth-er large nationally representative sam-ple (9). Similarly, Sirey and colleagues(10) found that beliefs about devalua-tion and discrimination toward individuals with mental illness were nega-tively related to treatment adherencein a sample of adults who had beenprescribed antidepressant medication.

Evidence from the literature on thegeneral population also suggests thatan individual’s own beliefs about peo-ple with mental illness may have im-portant implications for service use.For example, Cooper and colleagues(11) found that people who endorsedthe belief that individuals with psy-chiatric problems are responsible fortheir disorders and who reacted tothose individuals with anger were lesslikely to seek care for themselves when they needed it. Beliefs aboutmental health treatment also appear

to be implicated in service use. Forexample, Kessler and colleagues (8)found that among those who recog-nized a need for treatment, 45% re-ported perceived lack of effectivenessas a reason for not seeking treatment,and 19% of adults who indicated anunmet need for mental health care aspart of Ojeda and Bergstresser’s (9)study of a large nationally representa-tive sample identified negative atti-tudes about treatment seeking as anobstacle to care.

The goal of this study was to review the literature on beliefs about mentalhealth in regard to service utilizationamong military and veteran popula-tions and to identify conceptual andmethodological issues that warrant ad-ditional attention in future research inthis area. This article fills an importantneed by being the first to provide acritical review of this literature. In-cluded in the review were studies thatfall within two categories: those that

examined how concerns about publicstigma relate to mental health serviceuse and those that focused on how personal beliefs about mental illnessand mental health treatment relate tomental health service use. To set thestage for this review, a brief overview of the literature on barriers to care formilitary personnel and veterans is provided next, and the relevance of men-

tal health–related beliefs for thesepopulations is discussed.

Research on barriers to care in military and veteran populationsResearch on barriers to care for mili-tary personnel and veterans has bur-geoned over the past several decades,revealing a number of factors thatsubstantially affect service use andhealth outcomes (12–17). Many of these studies have applied Andersen’soriginal model (18) to address charac-teristics of an individual that influencehis or her likelihood to seek out men-tal health services. According to thismodel, use of services is a function of background characteristics that in-crease or decrease the likelihood thatone will use them (predisposing fac-tors), social circumstances that havean impact on ability to seek care (en-abling or impeding factors), and fac-tors that reflect one’s need for healthcare based on health status and func-

tional impairment (need-based fac-tors). Military and veteran studies thathave applied the Andersen modelhave addressed factors such as sex(15,19), age (20), service-connecteddisability status (19–21), and need forhealth care, as reflected in mental andphysical health symptoms (22,23).Findings have revealed a number of background characteristics that are as-sociated with increased service use.For example, prior research on the VAhealth care setting has shown that be-

ing male (19,24,25), being older (20,21), having a service-connected dis-ability (21), and having more severehealth problems (20) are all predictorsof more service use.

A separate line of research has fo-cused on characteristics of the healthcare environment that may increase ordecrease use of services, such as theavailability of services and ease of ac-cessing care. Much of this research hasfocused on the U.S. Department of

Veterans Affairs (VA) health care envi-ronment (12,13,26,27). Findings fromthe literature indicate that perceptionsof service availability play a key role inpredicting utilization of VA healthcare. For example, among female vet-erans, perceptions of the availability of services have been found to contributeunique variance in the prediction of VA health care use above and beyond

individual factors known to differenti-ate current from former users of VAhealth care (27). Results from samplesthat include men also indicate that waiting times and paperwork are per-ceived as significant barriers to VAhealth care (13,28). Consistent withthis perspective, among users of VAhealth care, difficulty navigating thehealth care system has been identifiedas a relevant barrier to care (12).

Another potentially relevant barrierto care for military and veteran popu-lations is personal beliefs about men-tal illness and mental health treat-ment. As discussed above, mentalhealth–related beliefs have been iden-tified as a key contributor to mentalhealth service use within the broaderliterature on the general population(29), and negative beliefs about men-tal health treatment may be an evenmore powerful deterrent to serviceuse in military and veteran popula-tions. Because of the high value

placed on emotional strength in themilitary, including, for example, theability to “tough out” difficult emo-tions (30), military and veteran popu-lations may be more susceptible thancivilians to negative beliefs aboutmental illness and mental health treat-ment. The relevance of mental healthattitudes among military and veteranpopulations is further underscored by the fact that the military includes alarge proportion of young men, agroup that may be especially suscepti-

ble to negative beliefs about mentalhealth treatment seeking (31–34).

Concerns about public stigma may also be compounded among military personnel to the extent that individu-als who experience mental healthproblems fear negative career conse-quences. In contrast to the civilian workplace, in which mental healthrecords are typically not available tosupervisors, in the military each serv-ice member’s commanding officer has

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access to his or her mental healthrecords, and those who are seen as “un-fit” for service may be discharged or re-moved from duty (31). There is alsosome evidence that concerns about po-tential career consequences associated with having mental health problemsmay continue to plague military per-sonnel who have left service. For ex-ample, in a recent focus group study

with OEF-OIF veterans, fear that VHA mental health records would beaccessible to potential federal and stateemployers was raised as a significantconcern of several participants (35).Consistent with this finding, prelimi-nary study findings based on a smallsample of female veterans of the con-flicts in Iraq and Afghanistan revealedthat 36% of female veterans whosought care outside the VHA identifiedconcern about harming their career asa reason for their decision (36).

The next section summarizes themilitary and veteran literature onmental health beliefs about serviceuse. Gaps in the literature are dis-cussed, and recommendations for fu-ture research are provided.

MethodsA review of PsycINFO and PubMedbibliographic databases was conduct-ed in September 2009. PsycINFOprovides abstracts and citations to the

scholarly literature in the psychologi-cal, social, behavioral, and health sci-ences from 1806 to the present.PubMed comprises more than 19 mil-lion citations in the fields of medicine,nursing, dentistry, veterinary medi-cine, the health care system, and pre-clinical sciences. PubMed, which in-cludes articles from 1879 to the pres-ent, provides access to MEDLINEand to citations for selected articles inlife science journals not included inMEDLINE. All available journal arti-

cles in both search engines were in-cluded in this review. The primary search terms that were used for thisreview were “attitudes” or “beliefs” or“stigma,” “mental health” or “mentalillness,” and “military” or “veteran.”In addition, a search of www.google.com was conducted to identify any ar-ticles that were recently publishedbut that had not yet been indexed inPsycINFO and PubMed, and col-leagues who were known to be study-

ing mental health–related beliefs inmilitary or veteran populations wereconsulted to identify any additional ar-ticles accepted for publication but not yet published (“in press”). Only arti-cles that reported either qualitative orquantitative data based on military or veteran samples were included in thisreview. All articles that were identifiedas “under review” or “in preparation”

were excluded.

ResultsThis review revealed only 15 articlesthat reported empirical data on mentalhealth beliefs about service use (Table1). Of these, 12 reported the results of quantitative studies (1,15,16,37–45)and three were based on qualitativestudies that either focused on mentalhealth–related beliefs or in whichmental health–related beliefs emergedas an important issue (28,46,47). Allbut two of the quantitative studies re-ported results relevant to concernsabout public stigma. In general, resultsof the literature review appear to sup-port the conclusion that concern aboutpublic stigma may be an importantbarrier to care. For example, almosthalf of all participants in a study of service members returning fromBosnia indicated that admitting a psy-chological problem would cause acoworker to maintain distance from

the service member (38), and approxi-mately one in three OEF-OIF veter-ans who participated in another study reported concern about public stigmaassociated with seeking mental healthcare (1). Similarly, fear of being la-beled as having a mental disorder wasa concern for 70% of OIF veterans who participated in Stecker and col-leagues’ (47) study on barriers to care,and concern about what others wouldthink if one were to seek mental healthcare was identified as one of the most

salient barriers to mental health careamong Kosovo peacekeepers (16).

Fewer studies examined the role of an individual’s own beliefs about men-tal illness and mental health treatmentas they relate to service use. As indi-cated in Table 1, of the quantitativestudies that were included in this review, only two focused primarily onpersonal beliefs about mental illnessand mental health treatment (39,41),and many of the studies that did in-

cluded only one or two items to assessthese beliefs. The available studies,however, indicate that these beliefsmay be important predictors of serviceuse. For example, Stecker and col-leagues (47) found that discomfort with treatment seeking, as reflected inthe belief that one ought to be able tohandle mental health problems onone’s own, was the most commonly re-

ported barrier to care in a sample of Vietnam and OEF-OIF veterans, andpride in self-reliance was identified asan important deterrent to treatmentseeking in a qualitative study of veter-ans with PTSD (46). Another study that examined the impact of personalbeliefs about mental health treatmenton service use in a sample of OEF-OIF veterans found that negative be-liefs about the nature of mental healthcare were significantly related to theuse of mental health services (42).

Overall, the sparse literature that isavailable appears to support the impor-tance of both concerns about publicstigma and personal beliefs about men-tal health as potential barriers to carefor military and veteran populations.However, this literature is character-ized by a number of limitations that aredescribed in the section below.

Discussion Personal beliefs about

mental illness and treatment

As noted above, much of the researchon mental health–related beliefs inmilitary and veteran populations hasfocused on concern about public stig-ma. Studies that have focused on individuals’ own beliefs about mental ill-ness and mental health treatment havegenerally not included a broad assess-ment of this construct, instead includ-ing only a few items for its assessment.Given ample evidence for the impor-tance of personal beliefs about mental

health in the general population, thisfactor warrants additional attention infuture research on military and veteranpopulations. On the basis of a broaderreview of the literature concerning thegeneral public, and pulling together what have largely been three separateresearch literatures, three potential do-mains of beliefs about mental healthmay be especially relevant here. Thesedomains include beliefs about people with mental health problems (48–51),



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Tabl e 1

Articles included in a review of mental health stigma research in military and veteran populationsa

Study type and article Study focus and constructs assessed Study sample Measure used

QuantitativeBritt, 2000 (37) Examined concerns about stigmatization and Current military Early version of Perceived Stigma and Bar-

comfort discussing psychological and medical personnel riers to Care for Psychological Problemsissues during screening of service members (PSBCPP) measurereturning from deployment to Bosnia

Britt et al., 2008 Examined concerns about public stigma and U.S. Army PSBCPP

(38) logistical barriers to care as moderators of soldiers andrelationship between stressors and psycholog- college studentsical symptoms (such as depression)

Edlund et al., 2008 Examined beliefs about depression (including VA patients Constructed measure of depression beliefs(39) concerns about public stigma) and depression (Depression Beliefs Inventory) to assess

treatment as predictors of initiating and ad- perceived need for depression treatment,hering to antidepressant treatment, as well beliefs regarding the efficacy of depressionas efficacy of an intervention on beliefs treatment, and beliefs about treatment bar-

riers, including an item to assess publicstigma

Fikretoglu et al., Examined concerns about public stigma and Canadian mili- Measure of barriers to care adapted from2008 (15) personal beliefs about mental illness and men- tary personnel the Perceived Need for Care Questionnaire

tal health treatment, as well as other potential (Meadows et al., 2000 [66]). The measurebarriers to care among military members who included the items “afraid of what others

met criteria for at least 1 mental disorder in the would think” and “didn’t have confidencepast year and who reported not receiving but in military health, administrative, or socialneeding mental health treatment services.”

Gould et al., 2007 Examined impact of PTSD psychoeducational UK military Concerns about public stigma items adapted(40) program on concerns about public stigma, per- personnel from the PSBCPP. Also developed a meas-

sonal beliefs about mental illness and mental ure of attitudes about mental illnesshealth treatment, and help seeking

Hoge et al., 2004 Examined rates of combat exposure and men- Military PSBCPP(1) tal health problems, as well as concern about personnel

public stigma and other potential barriers toseeking mental health care

Lysaker et al., 2008 Examined relationship between self-esteem Veterans and Used Internalized Stigma of Mental Illness(41) dimensions and beliefs about mental illness nonveterans Scale to assess aspects of self-stigma, includ-

and mental health treatment among veteran ing stereotype endorsement, discrimina-and nonveteran adults with schizophrenia tion experience, social withdrawal, stigmarejection, and stigma resistance

Maguen and Litz, Examined perceived barriers to seeking mental Military Measure adapted from National Vietnam2006 (16) health care, including concerns about public personnel Veterans Readjustment Study to assess po-

stigma and personal beliefs about mental illness tential barriers to care, including concernand mental health treatment among peace- about public stigma, personal beliefs aboutkeepers deployed to Kosovo, as well as predic- mental illness and mental health treatment,tors of perceived barriers to care and logistical barriers to care

Pietrzak et al., 2009 Examined social support and beliefs about Active duty and PSBCPP (Hoge et al., 2004 [1]) used to as-(42) mental health treatment as predictors of per- National Guard sess public stigma and logistical barriers.

ceived barriers to care (including concerns or military Items from the Beliefs about Psychotropicabout public stigma), as well as use of mental reserves Medications and Psychotherapy scale (Bys-health care services tritsky et al., 2005 [67]) were used to assess

beliefs about mental health treatment.Pyne et al., 2004 Examined association between concerns about Depressed and Public stigma: modified version of the 5-(43) public stigma and depression severity among never-depressed item Stigma Scale for Receiving Psycholog-

depressed and nondepressed veterans VA patients ical Help (Komiya et al., 2000 [68])

Warner et al., 2008 Examined soldier attitudes and preferences U.S. Army PSBCPP (Hoge et al., 2004 [1]) items to(44) with regard to mental health screening, treat- soldiers assess public stigma, along with an item that

ment, and perceived barriers to care, including focused on public stigma, a logistical item,concerns about public stigma and an item that addressed willingness to

take psychiatric medication

Wright et al., 2009 Examined leadership quality and unit cohesion U.S. Army PSBCPP (Hoge et al., 2004 [1]) to assess(45) as predictors of concerns about public stigma soldiers public stigma and logistical barriers to care

and logistical barriers to careContinues on next page

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beliefs about mental health treatment(52,53), and beliefs about treatmentseeking (6,54–56). Efforts to isolate theunique contribution of concerns aboutpublic stigma and personal beliefsabout mental illness and mental healthtreatment will make an especially valu-able contribution to the literature. The

literature review revealed no studiesthat examined and compared the rela-tive impact of these two factors onmental health service use.

Measurement of

mental health beliefs

Most of the studies that were includedin this review relied on measures of mental health beliefs that may not ade-quately reflect the complexity of thisconstruct or that have questionable orundocumented psychometric quality.

More specifically, seven of the 12quantitative studies identified in thisliterature were based on unvalidatedmeasures developed specifically for thepurpose of the study or scales that in- vestigators modified from other meas-ures. This is potentially problematicgiven that studies that rely on measuresof uncertain psychometric quality may produce results that are of question-able validity. Thus additional attentionto measurement issues with respect to

the assessment of mental health beliefsis encouraged in future research.

Of the 12 quantitative studies that were included in this review, six usedthe Perceived Stigma and Barriers toCare for Psychological Problemsmeasure or adapted this measure forthe particular study purposes. This

measure, which includes items that were first introduced in a study by Britt (37), focuses on public stigma as well as logistical barriers to care. Fu-ture research would benefit fromsupplementing measures of concernsabout public stigma like this one withpsychometrically sound measures of personal beliefs about mental illnessand mental health treatment. For ex-ample, researchers interested in as-sessing beliefs about people withmental illness might consider using

the stereotype agreement subscalefrom the Self-Stigma of Mental Ill-ness Scale (57). Also useful in this re-gard might be the Mental Illness Stig-ma Scale, which was developed to as-sess attitudes toward people withmental illness (50).

Mental health beliefs as

predictors of service use

Although the assumption that under-lies much of the research on mental

health beliefs is that concerns aboutpublic stigma and negative beliefsabout mental illness and mental healthtreatment serve as deterrents to serv-ice utilization, only one of the studiesincluded in this review reported re-sults that specifically addressed theimpact of mental health beliefs on use

of mental health services (42). Instead,most studies assessed how commonly mental health beliefs are reported as abarrier to care among those whodemonstrate need for care but do notseek out services. Although studiesthat require participants to identify factors that contribute to their deci-sion not to seek care are certainly use-ful and informative, what is perceivedas a key barrier may not always be what actually predicts use of services.For example, some individuals may

not feel comfortable acknowledging,or may not even realize, the role thattheir own or others’ biases about men-tal illness play in their willingness toseek out mental health care. Thusmore direct evidence is needed to con-firm the importance of mental healthbeliefs as a barrier to health care use.Therefore, a primary recommendationbased on this review is that researchersexamine mental health beliefs as pre-dictors of mental health service use.




Tabl e 1

Continued from previous page

Study type and article Study focus and constructs assessed Study sample Measure used

QualitativeSayer et al., 2009 Examined determinants of PTSD treatment Veterans apply- Open-ended questions about why people(46)b initiation among veterans who had submitted ing for VA dis- do or do not seek treatment

PTSD disability claims to VA. Both concerns ability statusabout public stigma and personal beliefs aboutmental illness and mental health treatment

emerged as important factors.Stecker et al., 2007 Examined beliefs about mental health treat- National Guard Open-ended questions about a range of (47)b ment among Iraq war soldiers who screened soldiers potential barriers to care, including beliefs

positive for a mental disorder. Both concerns about mental health careabout public stigma and personal beliefs aboutmental illness and mental health treatmentemerged as important factors.

Quantitative-qualitative Westermeyer et al., Examined perceived barriers to VA care among American Indian Open-ended question about perceived2002 (28)c American Indian veterans. Concerns about veterans barriers to VA care

public stigma and personal beliefs about men-tal illness and mental health treatment emergedas important factors.

a VA, U.S. Department of Veterans Affairs; PTSD, posttraumatic stress disorder; UK, United Kingdomb Semistructured interviews were conducted (the authors conducted these by telephone).c Coded interviews were used in the quantitative analyses.

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Further, research in this area wouldbenefit from the application of repre-sentations of service use that extendbeyond a simple assessment of “use” versus “no use.” For example, it is im-portant to examine the effects of men-tal health beliefs as they relate to whether one “walks through the door”to seek mental health treatment com-pared with how they relate to treat-

ment adherence.Finally, researchers who study the

association between mental health be-liefs and service use should carefully consider the direction of this associa-tion. As noted by Corrigan and Rusch(7), some people who do not pursuetreatment may rationalize this decisionin terms of stigma, so that lack of serv-ice use predicts mental health beliefsrather than vice versa. In addition,seeking mental health care may lead toan increase in perceptions of stigma,because stigma may become moresalient for those who seek care.Prospective designs that attend to thetiming of the assessment of attitudesabout mental health, the onset of men-tal health symptoms, and use of men-tal health services are needed to teaseapart the nature of this complex rela-tionship. None of the studies includedin this review examined the prospec-tive relationship between mentalhealth beliefs and service use; there-

fore, this is a key direction for futureresearch efforts.

Other potential barriers to care

Future research will also benefit fromcareful consideration of the larger con-text within which the decision to seekor not seek mental health care takesplace. The decision to seek mentalhealth care is likely to be influenced by many different factors, and it is impor-tant to isolate the unique effects of any given factor by examining it in the con-

text of other explanatory variables. Inparticular, it will be important to attendto logistical factors that may contributeto service use in studies of military and veteran populations (58). For example,studies that document the contributionof mental health beliefs to mentalhealth service use above and beyondbasic logistical issues, including factorssuch as availability of needed servicesand ease of use, will be particularly valuable. A strength of the Perceived

Stigma and Barriers to PsychologicalProblems measure (37) is that it in-cludes items to assess both concernsabout public stigma and logistical bar-riers to care. Future research that ex-amines the unique effects of these po-tential barrier categories on service use will provide an important contributionto the literature.

Likewise, studies that consider the

role of mental health–related beliefsin the context of institution-specificfactors unique to the particular type of health care service under investiga-tion will be especially valuable. Forexample, in our recent focus groups with OEF-OIF veterans, beliefs abouthow deserving one is to receive VAhealth care services, as well as one’sperception of fit within the VA healthcare setting, emerged as importantpotential predictors of service use(35). In addition, breaches of confi-dentiality and documentation of health problems in medical recordshave been identified as particular con-cerns for military personnel (44), giv-en that negative career consequencesmay result when commanding officersuse these medical records to informdecisions about whether a servicemember is fit to perform specific jobresponsibilities (31,59). Studies thatcan tease apart the unique effects of these and other potential barriers to

care will best inform clinical care andintervention efforts.

Subgroup differences in impact of

mental health beliefs on service use

Future research in this area shouldalso attend to the possibility that men-tal health–related beliefs and their im-pact on service use may differ acrossdifferent subgroups of military person-nel and veterans (including, for exam-ple, women versus men and younger versus older service members). Al-

though several studies presented hereexamined gender as a predictor of mental health–related beliefs, this review of the literature revealed no stud-ies that explored potential demo-graphic differences in the impact of mental health beliefs on service use.Yet, gender and racial-ethnic differ-ences may be of particular relevancefor this relationship (37). Evidencefrom the literature on the general pop-ulation indicates that men and persons

from racial-ethnic minority groups re-ceive less health care than women andCaucasians, and both gender andracial-ethnic minority status have beenidentified as correlates of attitudes,perceptions, and behaviors related tomental health care (54,60–62). For ex-ample, there is some evidence thatnegative attitudes about treatmentseeking are more salient among males

than females, possibly because mascu-line gender roles are predicated on asense of self-reliance and self-control(33,34). On the other hand, some find-ings indicate that concern about publicstigma (in this case, family reactions totreatment seeking) is a stronger pre-dictor of service use for women com-pared with men (52). Moreover, al-though few studies have examined joint effects of gender and race-ethnic-ity on mental health beliefs, a recentstudy found that concerns about pub-lic stigma and mistrust or fear of themental health system was a particularissue among white males (9). Thisfinding supports the importance of ex-amining the intersection of race-eth-nicity and gender in future studies.

Age is another factor that will beimportant to consider in future stud-ies of mental health–related beliefs.One recent study from the broaderliterature found that younger age wasassociated with more concern about

embarrassment with regard to usingmental health services, although in-terestingly, concerns about publicstigma predicted treatment discon-tinuation among older patients butnot younger patients (10).

ConclusionsEmpirical knowledge of mentalhealth–related beliefs that serve asbarriers to mental health service use iscritical to inform ongoing efforts to re-duce barriers to care within military

and veteran populations. Although theliterature examining this topic in themilitary and veteran populations issparse, the findings that are availablethus far appear to suggest that bothconcerns about public stigma and per-sonal beliefs about mental illness andmental health treatment may serve asimportant barriers to service use. Assuggested by this review of the litera-ture, there are several important di-rections for future research. In partic-




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ular, studies that address personal be-liefs about mental illness and mentalhealth treatment, that apply psycho-metrically sound measures to assessmental health beliefs, and that attendto the broader context within whichcare-seeking decisions are made canbe used to best target resources to en-gage military personnel and OEF-OIF veterans in health care. Evidence re-

garding aspects of mental health be-liefs that are most relevant to predict-ing service use can be used to more ef-fectively target interventions. For ex-ample, the finding that personal be-liefs about mental illness and mentalhealth treatment are stronger predic-tors of service use than concern aboutpublic stigma would suggest a very dif-ferent intervention strategy than thefinding that concern about public stig-ma is paramount. Likewise, researchfindings regarding group differencesin susceptibility to negative mentalhealth beliefs may be used to informdecisions about which groups are mostin need of intervention.

In contrast to many of the factorsthat have received a great deal of at-tention in the literature, mental healthbeliefs represent a potentially modifi-able factor and thus hold great prom-ise as a target of future efforts to re-duce barriers to care for those whoneed services most. Drawing from in-

tervention strategies that have beenused to combat public and self-stigmain the broader literature, results indi-cate that both education and contact with the stigmatized group may bepromising avenues for intervention(63,64). Educational interventions thatare targeted to both those experienc-ing mental health problems and thepopulation more generally may havedual benefits. Specifically, these interventions may reduce personal miscon-ceptions and negative stereotypes

about mental health–related issuesamong those who would benefit frommental health treatment, as well aspromote greater acceptance of treat-ment seeking in the population moregenerally. In addition, findings indi-cate that interventions that incorpo-rate contact with individuals who havemental health problems (for example,personal accounts of veterans’ experi-ences with stigma and treatment) may be an especially promising strategy to

target negative beliefs about mentalillness and mental health treatment(33,64,65).

As this review has revealed, the lit-erature on mental health beliefs asthey relate to service use among mili-tary personnel and veterans is still inits infancy. Yet this information is criti-cal to identify factors that interfere with the use of mental health services

by this population, and where possible,intervene to reduce barriers to care.Thus additional research attention tothis important topic is encouraged.

Acknowledgments and disclosures

This research was supported in part by grantDHI 06-225-2 from the VA Health Sciences Re-search and Development Service (“Stigma,Gender, and Other Barriers to VHA Use forOEF/OIF Veterans”). Additional support wasprovided by the National Center for Posttrau-matic Stress Disorder and the Massachusetts

Veterans Epidemiological Research and Infor-

mation Center (MAVERIC).

The authors report no competing interests.

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