Obstacles to PTSD take care of US veterans


Veterans usually expertise psychological well being difficulties, together with despair, anxiousness (Gould et al., 2014), and importantly, post-traumatic stress dysfunction (PTSD). PTSD is outlined as “reexperiencing the traumatic occasion, presence of intrusion signs, persistent avoidance of stimuli related to the traumatic occasion(s), and elevated arousal” (DSM-5, American Psychiatric Affiliation, 2013). PTSD prevalence amongst navy personnel varies, e.g., by service (Hines et al., 2014), however meta-analysis proof from Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) proof suggests a prevalence of round 23% (Fulton et al. 2015). Regardless of this excessive prevalence, solely a small variety of veterans with PTSD search assist when experiencing psychological well being difficulties (Possemato et al., 2018).

In a scientific evaluation by Hom et al. (2017), navy service members recognized confidentiality, embarrassment, and being seen as weak as a number of the most necessary boundaries to care. Different reported boundaries to help-seeking in navy personnel included profession considerations (e.g., Coleman et al., 2017) and sensible entry points (e.g., uncertain of the place to hunt assist, Murphy et al., 2016). Navy veterans are additionally involved about each inside and exterior stigma (Murphy & Busuttil, 2015). Obstacles to PTSD remedy packages have been proven to additionally differ by demographic. As an illustration, senior OEF/OIF veterans usually tend to determine boundaries associated to price and time commitments in comparison with youthful veterans (Garcia et al., 2014). To attain optimistic remedy outcomes and stop detrimental penalties, it’s essential to determine particular person traits that will hinder entry to care. This entails understanding boundaries to care.

The present examine (Rozek et al, 2023) used a nationwide pattern of US veterans to handle two goals:

  1. To quantify boundaries to assist searching for
  2. To determine variations in person-level traits (e.g., race, intercourse) within the boundaries to care.
a khaki camouflage army hat

What are the boundaries to care skilled by navy veterans with psychological well being difficulties? How do these boundaries differ by demographic?


17,069 veterans (Imply age=47.60 years, SD=14.18) referred to PTSD clinics within the division of Veterans Affairs (VA) in 2019 took half within the examine, together with those that self-referred and who have been referred by medical or psychological well being companies. The next knowledge was collected:

  • Demographic info: age, race, ethnicity, intercourse, intervals of navy service
  • The PTSD Standing Kind (PSF): a standardised template within the digital medical document, together with veterans’ demographic info, and boundaries to care akin to considerations regarding the monetary facet or social facets (household and relationships)
  • Presenting issues have been cut up into 9 classes (e.g., problematic remedy points) and have been rated by clinicians
  • Ache ranges (scale 0-10): veterans reported their ache ranges and the extent to which it interfered with their actions
  • PTSD Guidelines for DSM-V (PCL-5; Blevins et al., 2015): a 20-item self-report measure of PTSD signs. Contributors used a scale from 0 to 4 to charge their symptom severity, and their total rating was reported.

Evaluation technique

Eighteen binary logistic regressions have been carried out with every barrier as the end result variable to research whether or not there have been any important variations within the perceived boundaries based mostly on contributors’ demographics (e.g., gender).


Contributors have been primarily White (62.8%) males (83.3%) who have been OEF/OIF veterans (60.7%). On common, veterans’ PTSD signs severity was above medical threshold (>33) and indicative of PTSD (M=53.46; SD=14.51). On common, veterans reported greater than two boundaries to care (M=2.39, SD=2.27). Throughout demographic classes, the typical sum of presenting issues ranged from 1.41 (SD=0.76) for males to 1.82 (SD=0.95) for ladies. Presenting issues various by demographics additionally. As an illustration, navy sexual trauma was primarily reported by girls, whereas a historical past of Traumatic Mind Damage (TBI) was primarily reported by those that served throughout OEF/OIF.

an older man faces away from the camera, wearing a military beret, a crispy white shirt with a black badge on the arm, with his hand in a salute

Male, White, non Operation Iraqi Freedom/Operation Enduring Freedom veterans have been extra prone to report zero boundaries to remedy versus OIF/OEF, feminine or Black veterans.

The three most frequent boundaries recognized throughout the cohort have been:

  1. Work (30.3%)
  2. Difficulties being in public (33.8%), and
  3. Difficulties interacting with others (37.9%).

Nearly 1 / 4 of veterans reported no boundaries to care (22.3%).

The next important variations in particular person logistic regression fashions have been discovered:

  • Veterans who have been male, White, and had not served in the course of the OEF/OIF have been extra prone to endorse no boundaries to remedy, in comparison with those that served in the course of the OEF/OIF, girls, Black and ‘different’ (e.g., American Indian/Alaskan) race veterans.
  • OEF/OIF veterans have been extra prone to determine boundaries in relation to work, faculty, childcare, custody points, employment considerations, issue with getting away from bed/being in public, and felony justice considerations, in comparison with these not serving in the course of the OEF/OIF.
  • Black veterans have been extra prone to expertise boundaries that associated to housing, not getting together with household/pals, and difficulties with getting away from bed/interacting with others, in comparison with White veterans.
  • Veterans of ‘different’ (e.g., American Indian/Alaskan) races have been extra prone to expertise considerations round employment, housing, transportation, not getting together with household/pals, issue getting away from bed, and difficulties interacting with others, in comparison with White veterans.
  • Girls have been extra prone to categorical boundaries in relation to highschool, childcare, and issue getting away from bed, in comparison with males.
  • Males have been extra prone to determine employment, not getting together with household/pals, and felony justice considerations as a barrier, in comparison with girls.
Sad soldier in uniform covering his mouth while sitting on a sofa

In accordance with this analysis, the three largest boundaries to PTSD take care of veterans are: work, difficulties being in public and difficulties interacting with others.


  • Of all veterans surveyed, solely 22.3% reported having no boundaries to receiving remedy; all different contributors reported at the least one barrier.
  • Contributors of various ethnicities and genders confronted various boundaries. For instance, whereas 37.9% of all contributors had hassle interacting with others, Black veterans and people of different races have been extra prone to face this problem than White veterans.
  • Moreover, feminine veterans have been extra prone to report points associated to highschool and childcare, in comparison with their male counterparts.
soldiers in khaki camouflage uniforms march together perfectly in line

Over three quarters of greater than 17,000 veterans on this survey reported at the least one barrier to accessing psychological well being care, indicating areas for enhancements.

Strengths and limitations

The important thing strengths of this examine are its pattern dimension, the spectrum of measures used to painting veterans’ PTSD severity, and that the authors thought-about demographic info, and ache ranges. As well as, the authors additionally employed a stricter p-value (<.001) to interpret the info on account of a lot of analyses/contributors, growing our confidence within the outcomes.

Nevertheless, whereas veterans with at the least one go to to a PTSD specialty clinic may participate within the examine, the variety of visits per participant was not reported. It’s believable that contributors may have made just one go to to specialty clinics, whereas others may have made a considerably increased variety of visits. With out this info, the authors couldn’t discover the affiliation between boundaries reported and precise clinic visits, which might have offered richer perception into the potential impression of those boundaries total and for particular demographic teams.

Implications for follow

In PTSD clinics, clinicians might profit from assessing veterans on a person foundation. This might contain gathering each quantitative knowledge (such because the variety of boundaries) and qualitative knowledge (akin to how a selected barrier impacts a person) to completely perceive every veteran’s expertise of accessing care. This examine has recognized a number of boundaries which can be particular to sure demographic teams highlighting the significance of intersectional drawback. Earlier findings, for instance from Gross et al. (2022), have recognized racial disparities in PTSD remedy, the place Black veterans had poorer medical outcomes in comparison with White veterans. Proof offered on this paper on particular boundaries may shed some gentle on the mechanisms behind the disparities noticed in medical care outcomes, whereas additionally giving indications of points that must be rectified for veterans to entry acceptable care. For instance, for extra feminine veterans to entry care in a well timed and constant method, on-site choices for childcare might must be carried out or medical classes might must be provided remotely (Schlief et al. 2022).

Analysis has proven that evidence-based remedies akin to Cognitive Behavioral Remedy (Rothbaum et al., 2000), might be efficient in treating PTSD. Nevertheless, you will need to recognise that though care could also be out there clinically, there could also be invisible boundaries stopping veterans from accessing this care after they want it most. Structural and attitudinal change to assist help-seeking veterans could also be required with a purpose to guarantee parity of care throughout demographic teams.

a muscular man in a red t shirt and jeans sits on a sofa, learning forward, his face out of view, as if speaking to someone opposite

There could also be invisible boundaries stopping veterans from accessing psychological well being care after they want it most. Structural and attitudinal change could also be required to make sure parity of take care of veterans throughout demographic teams.

Assertion of pursuits

No conflicts of curiosity to declare.


Main paper

Rozek, D. C., Steigerwald, V. L., Baker, S. N., Gross, G., Maieritsch, Ok. P., Hoff, R., … & Smith, N. B. (2023). Understanding veteran boundaries to specialty outpatient PTSD medical care. Journal of Nervousness Issues, 95, 102675.

Different references

American Psychiatric Affiliation. (2013). Diagnostic and statistical guide of psychological problems (fifth ed.). Arlington, VA: Creator.

Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. Ok., & Domino, J. L. (2015). The posttraumatic stress dysfunction guidelines for DSM‐5 (PCL‐5): Improvement and preliminary psychometric analysis. Journal of traumatic stress, 28(6), 489-498.

Cameron, R. P., & Gusman, D. (2003). The first care PTSD display screen (PC-PTSD): growth and working traits. Main care psychiatry, 9(1), 9-14.

Coleman, S. J., Stevelink, S. A. M., Hatch, S. L., Denny, J. A., & Greenberg, N. (2017). Stigma-related boundaries and facilitators to assist searching for for psychological well being points within the armed forces: a scientific evaluation and thematic synthesis of qualitative literature. Psychological medication, 47(11), 1880-1892.

Fulton, J. J., Calhoun, P. S., Wagner, H. R., Schry, A. R., Hair, L. P., Feeling, N., … & Beckham, J. C. (2015). The prevalence of posttraumatic stress dysfunction in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans: A meta-analysis. Journal of hysteria problems, 31, 98-107.

Garcia, H. A., Finley, E. P., Ketchum, N., Jakupcak, M., Dassori, A., & Reyes, S. C. (2014). A survey of perceived boundaries and attitudes towards psychological well being care amongst OEF/OIF veterans at VA outpatient psychological well being clinics. Navy medication, 179(3), 273-278.

Gates, M. A., Holowka, D. W., Vasterling, J. J., Keane, T. M., Marx, B. P., & Rosen, R. C. (2012). Posttraumatic stress dysfunction in veterans and navy personnel: epidemiology, screening, and case recognition. Psychological companies, 9(4), 361.

Gould, C. E., Rideaux, T., Spira, A. P., & Beaudreau, S. A. (2015). Despair and anxiousness signs in male veterans and non‐veterans: The Well being and Retirement examine. Worldwide journal of geriatric psychiatry, 30(6), 623-630.

Gross, G. M., Smith, N., Holliday, R., Rozek, D. C., Hoff, R., & Harpaz-Rotem, I. (2022). Racial disparities in medical outcomes of Veterans Affairs residential PTSD remedy between Black and White veterans. Psychiatric companies, 73(2), 126-132.

Hamblen, J. L., Bernardy, N. C., Sherrieb, Ok., Norris, F. H., Prepare dinner, J. M., Louis, C. A., & Schnurr, P. P. (2015). VA PTSD clinic director views: How perceptions of readiness affect supply of evidence-based PTSD remedy. Skilled Psychology: Analysis and Observe, 46(2), 90–96. https://doi.org/10.1037/a0038535

Hines, L. A., Sundin, J., Rona, R. J., Wessely, S., & Concern, N. T. (2014). Posttraumatic stress dysfunction put up Iraq and Afghanistan: prevalence amongst navy subgroups. The Canadian Journal of Psychiatry, 59(9), 468-479.

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Kiernan, M. D., Osbourne, A., McGill, G., Jane Greaves, P., Wilson, G., & Hill, M. (2018). Are veterans completely different? Understanding veterans’ assist‐searching for behaviour for alcohol issues. Well being & social care locally, 26(5), 725-733.

King, A. P., Erickson, T. M., Giardino, N. D., Favourite, T., Rauch, S. A., Robinson, E., … & Liberzon, I. (2013). A pilot examine of group mindfulness‐based mostly cognitive remedy (MBCT) for fight veterans with posttraumatic stress dysfunction (PTSD). Despair and anxiousness, 30(7), 638-645.

Murphy, D., & Busuttil, W. (2015). PTSD, stigma and boundaries to help-seeking inside the UK Armed Forces. BMJ Navy Well being, 161(4), 322-326.

Murphy, D., Hodgman, G., Carson, C., Spencer-Harper, L., Hinton, M., Wessely, S., & Busuttil, W. (2015). Psychological well being and purposeful impairment outcomes following a 6-week intensive remedy programme for UK navy veterans with post-traumatic stress dysfunction (PTSD): a naturalistic examine to discover dropout and well being outcomes at follow-up. BMJ open, 5(3), e007051.

Murphy, D., Palmer, E., & Busuttil, W. (2016). Psychological well being difficulties and help-seeking beliefs inside a pattern of feminine companions of UK veterans recognized with post-traumatic stress dysfunction. Journal of medical medication, 5(8), 68.

Obuobi-Donkor, G., Oluwasina, F., Nkire, N., & Agyapong, V. I. (2022). A scoping evaluation on the prevalence and determinants of post-traumatic stress dysfunction amongst navy personnel and firefighters: Implications for public coverage and follow. Worldwide journal of environmental analysis and public well being, 19(3), 1565.

Possemato, Ok., Wray, L. O., Johnson, E., Webster, B., & Beehler, G. P. (2018). Facilitators and boundaries to searching for psychological well being care amongst major care veterans with posttraumatic stress dysfunction. Journal of Traumatic Stress, 31(5), 742-752.

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Schlief, M., Saunders, Ok. R., Appleton, R., Barnett, P., San Juan, N. V., Foye, U., … & Johnson, S. (2022). Synthesis of the Proof on What Works for Whom in Telemental Well being: Fast Realist Overview. Interactive Journal of Medical Analysis, 11(2), e38239.

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