This week's discussion is centered around an article published in February of 2020 in the Journal of Military Medicine. In this study, authors Duncan, Reed-Fitzke, Ferrero, Wojciak, Smith, and Sanchez aimed to identify potential barriers and facilitators to mental health treatment seeking among United States soldiers-in-training.
What did they do?
Using data collected from the New Soldier Study (NSS) component of the Army Study to Assess Risk and Resilience in Service-members (Army STARRS) between 2011 and 2012, the authors examined factors that are associated with both risk and resilience in connection to the likelihood of mental health help-seeking.
Why did they do it?
As highlighted by the authors, military personnel are at extraordinarily high risk for experiencing difficulties with mental health, as their work typically involves placement in a variety of stressful settings including combat, high demand training sites, deployment, and frequent job relocation. As we have discussed before, understanding barriers to treatment, as well as treatment seeking intentions are a critical component to consider when identifying intervention and prevention needs of potentially affected individuals.
The authors of this study used the Theory of Planned Behavior as a motivator to their study, as this theory is easily applicable to soldiers-in-training. This theory posits that “a person’s intention (motivation) and perceived behavioral control (ability) is directly associated with efforts to carry out behaviors and is a primary determinant of actual behaviors.” The authors used an example of soldiers-in-training, such that if soldiers-in-training are encouraged to seek counseling but have not previously engaged in help-seeking behavior prior to enlistment, they may have less motivation to utilize available services.
How did they do it?
Using data collected from a cross-sectional sample of new U.S. Army soldiers (n = 24,717), the authors examined demographics, help-seeking history, resilient mindset, stress intolerance, and a variety of specific mental health variables (e.g. depression, anxiety, PTSD experiences) and the associations of these variables with likelihood of treatment seeking.
What did they find?
The authors used hierarchical regression to examine the data, such that sets of predictors were entered into a predictive model one block at a time. In the first step of analysis, the authors examined demographics only as predictors of likelihood of treatment seeking. They found that those who identified as female, Hispanic, other race/ethnicity, and married, divorced, or separated reported a greater likelihood of seeking professional help. When risk factors were entered into the model, those reporting sexual trauma, impaired parenting, anxiety, depression, and PTSD symptomatology reported a greater likelihood of help-seeking. Individuals who reported emotional trauma and parental absence/separation reported a lower likelihood of help-seeking. In terms of resilience factors, individuals with a history of help-seeking reported a greater likelihood of seeking professional help.
Examining interactions between risk and protective factors yielded three significant interactions. First, an effect was found for history of help-seeking and depression, such that those who reported greater levels of depressive symptoms and a history of help-seeking reported a greater likelihood of help-seeking. The authors also found that the interactions of social network and sexual trauma, and social network and PTSD were inversely linked to the likelihood of seeking treatment.
What does it all mean (our take)?
We appreciate the author’s intentions with this study, and agree that continued examination of our military personnel is absolutely critical. Learning ways to engage members of the military with help-seeking behavior, particularly regarding mental health needs, has the potential to have significant positive downstream effects on their lives during and after their tenure with the military.
There are a couple of statistical pieces in this study to be discussed. First, the blocks used in regression models included broad groups (e.g., sex, relationship status, ethnicity, race), and thus the relationships between more specific factors and treatment seeking were not indicated. Additionally, and importantly, we see a good example of models that demonstrate statistically significant findings but perhaps not clinically meaningful findings. That is, while the blocks in regression models accounted for a statistically significant proportion of variance in the dependent variable, it is noted that the actual amounts of variance they accounted for were extremely low (in some cases <1%). This is not uncommon in studies with extremely large sample sizes, such as the current study, and thus these findings should be interpreted somewhat cautiously.
Nevertheless, we do not want that to take away from the intent of the authors. They have produced a study that we find to be critically important and we thank them for this work. Together we must continue to put forth effort in determining ways in which we can improve the likelihood of soldiers engaging in behavioral health services when needed, and it will likely start with trying to break down the stigma associated with behavioral health that is certainly present within this population (and generally, across most populations).