Open access
Research Article
21 November 2024

Army spouses’ mental health treatment engagement: The role of barriers to care

Publication: Journal of Military, Veteran and Family Health
Volume 10, Number 5

LAY SUMMARY

LAY SUMMARY

Military spouses are exposed to unique stressors that could put them at greater risk for developing mental health issues. Understanding how to support them is important for military family well-being and service member retention. This study examines barriers to care that army spouses with at least mild mental health symptoms experienced and explores whether these barriers prevented them from seeking mental health treatment. Findings suggest military spouses experience a variety of barriers. Spouses experiencing mental health symptoms may struggle to get care if they have at least one child, are employed full- or part-time, or report greater stigma toward mental health care. Additional research is needed to better understand the complexity of barriers and how these barriers contribute to care over time.

Abstract

Introduction: Military spouses are exposed to unique stressors that could put them at greater risk for developing mental health issues requiring mental health services. This study examines the impact of barriers to mental health care on army spouses’ treatment engagement, controlling for socio-demographic variables and mental health symptoms. Methods: This study is a secondary analysis of survey data collected in 2012 from 327 U.S. Army spouses from a previously deployed army unit. Results: Factor analysis of a barriers-to-care scale revealed four sub-scales: 1) perceived stigma, 2) practical barriers to care, 3) self-management, and 4) attitudes toward care. Using multivariable logistic regression, among army spouses with at least mild mental health symptoms, being employed full- or part-time (OR = 0.13, 95% CI, 0.02–0.82), having at least one child (OR = 0.09, 95% CI, 0.01–0.61), and endorsing psychological barriers to care (OR = 0.82, 95% CI, 0.72–0.95) were associated with lower likelihood of using mental health services, while reporting more practical barriers (OR = 2.06, 95% CI, 1.36–3.14) was associated with a greater likelihood. Discussion: Preliminary results show army spouses experiencing at least mild mental health symptoms may struggle to get care if they have at least one child or if they are employed full- or part-time. Those who report more stigma about mental health care may be less likely to seek care. The counterintuitive association between practical barriers, such as difficulty with scheduling an appointment, and being in treatment, may reflect that those in care are more likely to experience these issues.

Résumé

Introduction : Les conjoint(e)s des militaires sont exposé(e)s à des facteurs de stress uniques qui peuvent les rendre plus vulnérables à des troubles de santé mentale qui exigeront des services de santé mentale. Cette étude explore les répercussions des obstacles aux soins en santé mentale sur la mobilisation thérapeutique des conjoint(e)s de militaires, compte tenu des variables sociodémographiques et des symptômes de troubles de santé mentale. Méthodologie : Cette étude est une analyse secondaire de données du sondage obtenues en 2012 auprès de 327 conjoint(e)s de militaires d’une unité de l’armée américaine qui avait déjà été déployée. Résultats : L’analyse des facteurs de l’échelle des obstacles aux soins a révélé quatre sous-échelles : 1) les stigmatismes perçus, 2) les obstacles pratiques aux soins, 3) la prise en charge personnelle et 4) les attitudes envers les soins. À l’aide de la régression logistique multivariée, chez les conjoint(e)s des militaires qui présentaient au moins des symptômes légers de troubles de santé mentale, un emploi à temps plein ou partiel (RC = 0,13, IC à 95 %, 0,02 à 0,82), le fait d’avoir au moins un enfant (RC = 0,09, IC à 95 %, 0,01 à 0,61) et l’acceptation d’obstacles psychologiques aux soins (RC = 0,82, IC à 95 %, 0,72 à 0,95) étaient associés à une plus faible probabilité d’utiliser des services en santé mentale, tandis que la déclaration d’un plus grand nombre d’obstacles pratiques (RC = 2,06, IC à 95 %, 1,36 à 3,14) était liée à une plus grande probabilité de les utiliser. Discussion : Selon les résultats préliminaires, les conjoint(e)s de militaires qui éprouvent au moins un symptôme léger de trouble de santé mentale peuvent avoir de la difficulté à obtenir des soins s’ils(si elles) ont au moins un enfant ou s’ils(si elles) sont employé(e)s à temps plein ou partiel. Ceux et celles qui déclarent plus de stigmatisation envers les soins en santé mentale peuvent être moins susceptibles de demander des soins. L’association contre-intuitive entre les obstacles pratiques, tels que la difficulté à obtenir un rendez-vous, et le fait d’être en cours de traitement peuvent refléter le fait que les personnes qui sont soignées sont plus susceptibles d’éprouver ces problèmes.

INTRODUCTION

Close to 1 million U.S. military spouses may experience unique stressors related to a partner’s military service.1 These stressors include prolonged separations during deployment or training, worry about their partner’s health and well-being during deployments, and frequent relocation that can uproot them from communities and employment.2,3 Recent research showed most spouses cope well with the stressors of being married to someone in the military.4 However, research also documented higher prevalence of mental health issues in female spouses when compared to non-military-affiliated women in the United States.5
Supporting military spouses in receiving mental health care is important not only for their health but also for the health of military families and retaining service members.6,7 Previous research explored logistical and psychological barriers military spouses experience when accessing mental health treatment.8,9 While this work focused on perceived barriers to treatment, it did not examine treatment use.9 Furthermore, prior work did not control for a variety of socio-demographic variables, including spousal employment or prior military history. Understanding how different barriers can impact mental health care engagement, while accounting for socio-demographic characteristics, will offer a more nuanced understanding of mental health care use for a diversity of military spouses.
This study builds on prior work that examined barriers to mental health care in service members by exploring the impact of a variety of perceived barriers on actual care use in a sample of army spouses experiencing mental health symptoms. Overall, this article seeks to understand what types of barriers to care army spouses experience and whether certain barriers affect mental health care use for those with at least mild mental health symptoms, while controlling for several socio-demographic variables.

Practical barriers to mental health care

Previous military research identified two main barriers to care: practical barriers and perceived stigma.811 Practical barriers to mental health care include organizational barriers, such as lack of availability of appointment times or long wait times to get an appointment, as well as personal barriers, such as not having time to go to an appointment.9 Considering that all active duty military spouses are afforded the same health care benefits, one might expect there would be minimal practical barriers to mental health care treatment.12 However, even in this context, there can be obstacles to seeking treatment, including differing resources at each military installation. For example, larger installations tend to have more resources, including hospitals.13,14 Previous research highlighted several potential practical barriers to mental health care, including difficulty attending daytime appointments, availability of counsellors trained to meet the needs of military families, lack of transportation, and lack of knowledge about where to find services.8,9,11 One of the most common practical barriers is the inability to leave work or household responsibilities to attend a daytime appointment.9,11 Several contextual factors may account for these findings, including increased child care and household responsibilities during deployment or training separations.15,16 These results indicate that, even in a context with equal health care benefits, practical barriers can still be substantial.

Perceived stigma and mental health care

Perceived stigma about mental health care is broadly defined as a thought or fear of a perception that prevents an individual from seeking or receiving care.9 Perceived stigma is a documented problem for both spouses and service members seeking care.8,16,17 Spouses report concerns seeking mental health treatment will adversely affect others’ opinions of, and confidence in, them,8,17 which carries significant consequences in the military context where personnel and their families are expected to be mission ready.9,16 Further, spouses express concerns that seeking treatment can limit their partners’ opportunities for promotion, advancement, and security clearances, and can lead to separation or removal.16 Lewy and colleagues11 compared psychological barriers among military wives, including perceived stigma, with a national sample of non-military-affiliated women and found military wives to have significantly more psychological barriers to mental health treatment than the national sample. Collectively, the minimal research documenting military spouses’ perceived stigma about mental health treatment indicates a need for further research on how these perceptions impact engagement in mental health services.

Socio-demographic factors and barriers to mental health care

Schvey and colleagues9 examined perceived barriers to mental health care in a large sample of nearly 10,000 U.S. military spouses and found significant differences in reported barriers to care across gender, race, military service experience, and level of behavioral health symptoms. For example, racial and ethnic minority spouses were less likely to report logistical barriers and internalized mental health stigma than non-Hispanic white respondents. Spouses who previously served, or were currently serving in the military, were significantly more likely to report negative beliefs about mental health care, as well as to perceive negative consequences of seeking care.9 This highlights the importance of understanding spouses’ history with the military, as that can impact perceptions of mental health treatment.9,15
However, this large-scale study did not assess the relationship between barriers to care and actual treatment engagement and did not account for important socio-demographic factors that could impact perceived barriers. For example, employment is an important socio-demographic variable that could impact health care use, as it may increase demands on a spouse’s time, potentially restricting the ability to access services.18,19 Another socio-demographic factor that could impact perceived barriers is whether or not a spouse has children. Children can add logistical barriers, such as child-care planning, to appointment attendance. Child care is a known stressor for military spouses.2022 This study will consider socio-demographic factors that can impact mental health care engagement. It tested the following hypothesis: there will be an inverse relationship between reported barriers to care and treatment engagement among army spouses, after controlling for socio-demographic variables.

METHODS

Data and participants

Secondary data from the Land Combat Study was used for this study, which was conducted by Walter Reed Army Institute of Research (WRAIR) in 2012. The project was approved by the WRAIR Institutional Review Board. Details on study procedures were previously published.23 Spouses were recruited through coordinated efforts with the brigade’s Family Readiness Group (FRG) leaders in 2012. The FRG is a command-sponsored organization of family members, volunteers, and soldiers belonging to a unit that provides an avenue of mutual support and assistance to family members. Military spouses were informed about the study and asked to provide informed consent. A total of 23% of FRG spouses responded to recruitment. Surveys were administered in person and online with all participants in the continental United States. Each survey took between 30 and 45 minutes to complete. Of the responding spouses, 98% agreed to take part in the study. Approximately 74% of individuals completed a web-based version of the survey; 26% completed a paper version. Spouses who currently serve in the military were excluded from the sample, as were male spouses, because prior research indicated civilian female spouses have unique experiences gaining and maintaining employment and are more likely to develop mental health issues related to balancing work and family life.2427 Nine male spouses and seven female spouses who indicated they were currently serving in the military were removed from further analyses. Female spouses with a history of military experience were included in the analyses because they were not currently serving. Additionally, 180 spouses who did not meet the clinical thresholds for at least mild mental health symptoms (based on validated scales for depression, anxiety, and posttraumatic stress disorder [PTSD]) were removed, for a final analytic sample of 146 female civilian spouses. Most of our sample was non-Hispanic white (75%), was married to, or partnered with, an enlisted service member (82%), had less than a bachelor’s degree (69%), had no prior familial or personal service history with the military (73%), were 18–29 years old (53%), had at least one child (63%), and had no paid employment (72%; see Table 1).
Table 1. Descriptive statistics
Characteristic N (%)Range
Race/ethnicityNon-Hispanic white110 (75%)
Non-white36 (25%)
Spouse rankEnlisted119 (82%)
Officer26 (18%)
Employment statusEmployed41 (28%)
 No paid employment105 (72%)
EducationBachelor’s degree or more45 (31%)
Less than bachelor’s degree101 (69%)
Age18–29 years old78 (53%)
30+ years old68 (47%)
Personal history with militaryNo103 (73%)
Yes39 (28%)
Has at least one childNo54 (37%)
Yes92 (63%)
Currently in mental health treatmentNo126 (87%)
Yes19 (13%)
  Mean (SD) 
Depression symptoms6.9 (4.8)0, 24
Anxiety symptoms7.4 (4.4)0, 21
PTSD symptoms30.5 (12.7)17, 85
PTSD = posttraumatic stress disorder.

Measures

Perceived barriers

A total of 24 items measured perceived barriers to mental health treatment. Participants were asked to “please rate how much you agree or disagree with the following factors related to receiving mental health counseling or services.” Most of the items were originally developed for active duty service members and demonstrated good validity and reliability.28 Here, the items were slightly adapted to be tailored to military spouses. For example, questions specific to the service member, such as “my unit leadership might treat me differently” were removed, and questions specific to a military spouse, such as “it would harm my spouse’s career” were added. Responses were given on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). One item, “mental health services are not available to me,” was left unanswered by more than 70% of participants, so it was removed from analysis. Factor analysis was conducted on the remaining 23 items. Two positively worded questions, “it takes courage to get treatment for mental health problems,” and “mental health counseling can be helpful for those who need it,” were included to assess potential facilitators to care.

Socio-demographic variables

Seven self-report demographic measures were used in this study. Education (less than a bachelor’s degree/bachelor’s degree or more) and employment status (employed full- or part-time/no paid employment and looking/not looking for work) were self-reported. There were 37 write-in responses that were recorded into employed (n = 4) and no paid employment (n = 24) because they indicated they either worked, or did not, in the description. Race/ethnicity was self-reported as non-Hispanic white/non-white (Black/non-white Hispanic/Asian/Pacific Islander and those that marked “other”). Rank of spouse (enlisted/officer), age (18–29 y/30+ y), and number of children (none vs. 1+) were all self-reported. History with the military (yes/no) was assessed with one item, which asked spouses to indicate whether any of the following experiences applied to them: “I am/was a military service member,” “I grew up in a military family,” or “I was a military spouse in a prior marriage.” A yes response to any of these three items was indicative of having a personal history with the military.

Mental health

To create the clinical analytic sample, three screening measures were used for mental health: the Patient Health Questionnaire-8 (PHQ-829), the Generalized Anxiety Disorder-7 (GAD-730), and the PTSD Check List-17 (PCL-1731). The PHQ-8 and GAD-7 assess depression and anxiety symptoms, respectively, over the previous two weeks and have response options ranging from 1 (not at all) to 4 (nearly every day). Item responses are summed, with higher scores indicating greater severity. The PCL-17 also asks respondents how often they were bothered by symptoms in the previous two weeks. Response options range from 1 (not at all) to 5 (extremely). Internal consistency for all scales were good in this sample (PHQ-8: Cronbach’s α = 0.89; GAD-7: Cronbach’s α = 0.88; PCL-17: Cronbach’s α = 0.93). A score of 5 or more on the PHQ-8 or GAD-7 measure is the cut-off point for clinically significant mild depression or anxiety symptoms, respectively.30,32 A score of 43 or more on the PCL-17 was used to indicate a screening is needed for potential PTSD.33,34

Mental health treatment

Mental health treatment of spouses was assessed through the question “are you currently in mental health treatment?” with response options 1 (yes) or 0 (no). This type of question has been used in other military mental health studies.35

Data analysis

STATA 16.1 (StataCorp, College Station, TX) was used for data cleaning and all analyses. As this sample was comparatively small, several choices were made in recoding to preserve power. For example, race/ethnicity is represented as non-Hispanic white/Hispanic non-white, and education is represented as less than a bachelor’s degree/bachelor’s degree or more. These choices were consistent with how data have previously been used.23 All potential variables of interest had an acceptable level of missingness (less than 8%36). A principal component exploratory factor analysis with the varimax orthogonal rotation was used on the barriers-to-care questionnaire to inform use of the scale in the regression analysis37 (see Table 2 for the questionnaire). Bivariate correlations were run to assess for possible multicollinearity.38 Basic descriptive statistics were used to understand the distribution of barriers among army spouses with at least mild mental health symptoms. Multivariable logistic regression was used to assess the relationship between predictors and dichotomous outcome (engaged in mental health treatment or not).36
Table 2. Factor analysis of barriers to care scale for military spouses
Sub-scaleFactor loading
Psychological barriers to care; Cronbach’s α = 0.92
 It would be too embarrassing.0.86
 It would harm my career.0.69
 I would be seen as weak.0.90
 It would harm my spouse’s career.0.76
 Others would think less of me.0.91
 Others would blame me.0.65
 My spouse would disapprove of me receiving help.0.64
 My visit would not remain confidential.0.63
Practical barriers; Cronbach’s α = 0.73
 It would be difficult to schedule an appointment.0.95
 It would be difficult getting time away from my responsibilities (work, children, etc.) for treatment.0.52
Self-management; Cronbach’s α = 0.81
 There is sufficient information available for people to be able to help themselves.0.54
 I know how to help myself.0.65
 Strong people can resolve psychological problems by themselves.0.64
 I would prefer to manage my problems on my own.0.79
 People should be able to solve their psychological problems themselves.0.69
 I would rather get information on how to deal with the problems on my own.0.69
Attitudes toward care; Cronbach’s α = 0.60
 It takes courage to get treatment for a mental health problem.0.67
 Mental health counseling can be helpful for those who need it.0.73

RESULTS

Most spouses indicated they were not currently in mental health treatment (87%). Since this was a sub-sample of army spouses that met clinical thresholds for either mild depression, anxiety, or PTSD, it meant most army spouses in this sample had at least mild mental health symptoms (see Table 1).
Principal component factor analysis of the barriers to care scale revealed four sub-scales: 1) perceived stigma (Cronbach’s α = 0.92), 2) practical barriers (Cronbach’s α = 0.73), 3) self-management (Cronbach’s α = 0.81), and 4) attitudes toward care (Cronbach’s α = 0.60). Perceived stigma had eight items, practical barriers had two items, self-management had six items, and attitudes having adequate transportation, thinking getting mental health treatment should be a last resort, not trusting mental health professionals, and thinking they knew how to help themselves, did not load above a 0.4 on any sub-scale and were removed.39 The sub-scales found are similar to those used among active service members28 (Table 2). Pairwise correlation analyses revealed the majority of correlations were weak (0 <= |r| < 0.3), with three indicating a moderate relationship (0.3 ≤ |r| < 0.7) and none demonstrating a strong relationship |r| >= 737 (Table 3). Therefore, no analytic adjustments were required for regression analyses.
Table 3. Pairwise correlation coefficients among barriers to mental health care and treatment usage among army spouses
Variables(1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)
(1) In MH Tx1.00           
(2) White0.121.00          
(3) Officer−0.130.101.00         
(4) Employed−0.060.040.031.00        
(5) Bachelor’s +−0.040.040.62**0.111.00       
(6) Young0.120.07−0.17*−0.03−0.031.00      
(7) Has child−0.08−0.04−0.05−0.22**−0.07−0.26**1.00     
(8) Mil. history0.03−0.020.000.100.02−0.03−0.011.00    
(9) Prac. barriers0.19*0.11−0.060.140.100.020.31**−0.101.00   
(10) Psyc. barrier−0.21*−0.040.13−0.030.12−0.040.13−0.080.42**1.00  
(11) SM. barriers−0.21v−0.010.020.07−0.07−0.080.07−0.040.18*0.32**1.00 
(12) ATC0.130.17*−0.010.01−0.090.000.150.140.03−0.060.081.00
(1) Currently in mental health treatment. (2) Non-Hispanic white vs. Hispanic & non-white. (3) Officer vs. enlisted. (4) Employed vs. no paid employment. (5) Bachelor’s degree or more vs. less than bachelor’s degree. (6) Young (18–29 y) vs. older (30+ y). (7) Has at least one child vs. does not have children. (8) Has a history with the military vs. not. (9) Practical barriers to mental health care. (10) Psychological barriers to mental health care. (11) Self-management barriers. (12) Attitudes toward care.
*
p ≤ 0.05.
**
p ≤ 0.01.
Multivariable logistic regression was run on the sub-sample of 146 spouses to examine the relationship between socio-demographic characteristics and the four barriers to care sub-scales and the odds of participating in mental health services among army spouses who experienced at least mild mental health symptoms. This model was significant (likelihood ratio χ2: 36.11; p < 0.001; Pseudo R2 = 0.34) and results are displayed in Table 4. Four independent variables were significantly related to mental health services use: 1) employed full- or part-time (OR = 0.13, 95% CI, 0.02–0.82), 2) has at least one child (OR = 0.09, 95% CI, 0.01–0.61), 3) psychological barriers to care (OR = 0.82, 95% CI, 0.72–0.95), and 4) practical barriers (OR = 2.06, 95% CI, 1.36–3.14). Race, spouse rank, education achieved, age, military history, and the other barrier sub-scales of self-management and positive attitude were not significantly associated with treatment use.
Table 4. Logistic regression predicting current mental health services use
VariableBSEOR95% CI
Non-Hispanic white (vs. Hispanic non-white)0.902.232.450.4114.56
Officer (vs. enlisted)−0.690.710.500.037.97
Employed (vs. no paid employment)−2.060.120.13*0.020.82
Bachelor’s degree (vs. less than bachelor’s)−0.200.740.820.144.85
Young (vs. older, 30+ years)−0.180.610.840.203.48
Has at least one child (vs. had none)−2.440.090.09*0.010.61
Prior history with military (vs. none)0.381.091.460.346.30
Practical barriers to care0.730.442.06**1.363.14
Psychological barriers to care−0.190.060.83*0.720.95
Self-management barriers to care−0.120.070.880.761.02
Attitudes toward care
−1.56
0.24
1.23
0.84
1.81
Model characteristics

Likelihood ratio χ236.11    
Number of observations130    
Pseudo R20.35    
B = unstandardized beta; SE = standard error; OR = odds ratio; CI = confidence interval.
*
p ≤ 0.01.
**
p ≤ 0.001.
***
p ≤ 0.000.

DISCUSSION

This study assessed how barriers to mental health treatment affected mental health care use in a sample of army spouses experiencing mental health symptoms. This study builds on previous research that explored health care engagement in this population by including a variety of socio-demographic factors, such as race/ethnicity, spousal rank, employment status, age, education level, parenthood, and personal history with the military.
The military spouse barriers-to-care questionnaire revealed four different types of barriers that could affect care use: 1) perceived stigma, 2) practical barriers, 3) self-management, and 4) attitudes toward care. Perceived stigma and practical barriers were reported in prior literature as important factors to consider when assessing military spouse mental health treatment engagement.8,9,11 The barriers to care questionnaire is optimal for use with spouses because it has been adapted to address unique barriers to mental health care for military spouses. Items were adapted to capture stigma in the military population (e.g., “it would harm my spouse’s career,” and “my spouse would disapprove of me receiving help”). With mental health stigma being relatively higher in the military than the general population, this is an important construct to assess in the military spouse population. This study adds that there may be additional barriers, such as beliefs people should be capable of managing mental health themselves (self-management), as well as how they view the utility and benefits of mental health care in general (attitudes toward care). While this preliminary study did not find these additional sets of barriers to be significantly related to treatment engagement for army spouses, future research should consider how other barriers could impact mental health use for military spouses.
The authors hypothesized more reported barriers to care would be associated with lower odds of being in care; this hypothesis was partially supported. Controlling for a variety of socio-demographic variables, spouses who reported more perceived stigma toward mental health treatment were significantly less likely to receive mental health services. These findings are similar to those found among soldiers, in that mental health stigma is cited as a main barrier to seeking care.40,41 These findings are concerning when prior research suggests military wives are more likely than their civilian peers to report psychological barriers like perceived stigma.11 This finding emphasizes the importance of continued efforts to decrease mental health stigma in the military for spouses through building a culture of support for psychological health.42
However, considering these, and other findings, efforts to reduce stigma may not go far enough to address this obstacle to service engagement. Another strategy to reduce perceived stigma to mental health services could be to describe these services using terms that are not as stigmatizing for this population. For example, the family-based resiliency intervention Families OverComing Under Stress (FOCUS) is used across the globe on various naval and Marine bases to provide preventative mental health support for military families.4345 While the FOCUS program is an adaptation of several family-based treatments to support the mental well-being and functioning of families, FOCUS markets itself as a resiliency-building intervention to support the mission readiness of military families, in acknowledgement of the potential stigma that surrounds family therapy in this population.43 However, no formal studies have been conducted to determine whether this rebranding has led to greater mental health care engagement over other programs that use more traditional health service terms.
The authors found army spouses who experienced at least mild mental health symptoms and practical barriers to care were more likely to be in treatment. While this was unexpected, a similar relationship was observed in a study of treatment-seeking, previously deployed soldiers, in which organizational barriers were positively associated with use of civilian mental health care.28 These findings could be due to the nature of cross-sectional data, reflecting that those in care are more likely to be aware of barriers like scheduling appointments and taking time away from other responsibilities. Future research assessing barriers to care should be conducted longitudinally to better assess the temporality of this relationship.
Army spouses employed full- or part-time or with at least one child were less likely to engage in mental health treatment. Other research on mental health treatment engagement for mothers showed employment was significantly related to less attendance in treatment.46 Studies in the medical community showed mothers provided with free child care were better able to adhere to scheduled medical appointments.47 This study builds on this literature by showing that army spouses experiencing at least mild mental health symptoms, and having other responsibilities such as taking care of a child or working, may need extra support in treatment. Future research should qualitatively explore specific supports for army spouses who attempt to engage in mental health treatment.

Limitations

These findings should be considered in light of several limitations. This study was a secondary analysis of data collected 10 years ago. However, the data were collected at a potentially stressful time for spouses, as 2012 was a time of high operational tempo. Additionally, as this study was cross-sectional, directionality between associated variables cannot be definitively determined and ability to track change over time is not possible. However, these data are useful because they offer an opportunity to consider factors associated with mental health treatment use at a time of particularly elevated military-related stressors. The sample used for this analysis was small and limited in its racial/ethnic and rank diversity; however, this sample is representative of the military spouse community as it is primarily white, associated with junior-ranking service members, and female.1 Non-probability sampling with a 23% response rate from eligible spouses could introduce non-response bias and potentially limits generalizability. Several decisions were made to preserve power, such as collapsing race/ethnicity and employment status demographic categories. Therefore, comparisons across these sub-groups were not possible. The dichotomization of race/ethnicity fails to account for the various groups incorporated into non-white and that they may not have the same experiences with mental health treatment use. Additionally, information on spouse age was collected as a categorical variable; thus, it could not be treated as a continuous variable. Because of the small sample size, age was dichotomized to preserve power.
Finally, while previous experiences with mental health care can be relevant for current and future treatment seeking, analyses did not include a measure of past mental health treatment or intention to seek treatment because the data set did not contain this information. Additionally, the authors did not assess what participants may have meant by mental health treatment, such as having a conversation with their primary care doctors who then wrote them a prescription or going to talk therapy. Future research should tease out different versions of mental health services with a more nuanced set of outcomes.

Conclusion

Future research should also assess perceived barriers to care after the COVID-19 pandemic, as telehealth services have increased access and proven to be effective at treating mental illness (see Rauschenberg et al. for meta-analysis).48 Access to telehealth services may increase use in the military spouse population, as this mode of service delivery may minimize some practical and perceived stigma barriers. For example, a military spouse does not have to worry about being seen in, or near, the treatment office if they are able to receive services at home.49 Additionally, considering stigma toward mental health care among this population, future research should explore military spouse treatment preferences and current health care engagement. These findings suggest a need for solutions to promote enduring and trusting relationships with military providers, and telehealth could be a promising solution.

ACKNOWLEDGEMENTS

Special thanks to Julie Merrill and Kristina Clarke-Walper for their invaluable work on this study. The authors would like to acknowledge all the military spouses who support a service member and the spouses who took the time to participate in this study.

REGISTRY AND REGISTRATION NO. OF THE STUDY/TRIAL

N/A

ANIMAL STUDIES

N/A

PEER REVIEW

This manuscript has been peer reviewed.

REFERENCES

1.
U.S. Department of Defense. 2019 demographic profile of the military community [Internet]. Arlington: Department of Defense and Office of the Deputy Assistant Secretary of Defense for Military Community and Family Policy; 2019 [cited 2021 Jan 17]. Available from: https://download.militaryonesource.mil/12038/MOS/Reports/2019-demographics-report.pdf
2.
Marini CM, Collins CL, MacDermid Wadsworth SM. Examining multiple rhythms of military and Veteran family life. J Fam Theory Rev. 2018;10(3).
3.
MacDermid Wadsworth SM. Understanding and supporting the resilience of a new generation of combat-exposed military families and their children. Clin Child Fam Psychol Rev. 2013;16(4):415–20.
4.
Sullivan KS, Hawkins SA, Gilreath TD, Castro CA. Mental health outcomes associated with profiles of risk and resilience among U.S. Army spouses. J Fam Psychol. 2021;35(1):33–43. Epub 2020.
5.
Steenkamp MM, Corry NH, Qian M, et al. Prevalence of psychiatric morbidity in United States military spouses: the millennium cohort family study. Depress Anxiety. 2018;35(9):815–29.
6.
Green S, Nurius PS, Lester P. Spouse psychological well-being: a keystone to military family health. J Hum Behav Soc Environ. 2013;23(6):753–68.
7.
Rosen LN, Durand DB. The family factor and retention among married soldiers deployed in operation desert storm. Mil Psychol. 1995;7(4):221–234.
8.
Eaton KM, Hoge CW, Messer SC, et al. Prevalence of mental health problems, treatment need, and barriers to care among primary care-seeking spouses of military service members involved in Iraq and Afghanistan deployments. Mil Med. 2008;173(11):1051–56.
9.
Schvey NA, Burke D, Pearlman AT, et al. Perceived barriers to mental healthcare among spouses of military service members. Psychol Serv. 2022;19(2):396–405. Epub 2021 April.
10.
Adler AB, Britt TW, Riviere LA, et al. Longitudinal determinants of mental health treatment-seeking by US soldiers. Br J Psychiatry. 2015;207(4):346–50.
11.
Lewy CS, Oliver CM, McFarland BH. Barriers to mental health treatment for military wives. Psychiatr Serv. 2014;65(9):1170–3.
12.
Military.com [Internet]. San Francisco: Military Advantage. Military spouse and family benefits. 2022 Jun 15 [cited August 2024]. Available from: https://www.military.com/spouse/military-benefits/military-spouse-and-family-benefits-101.html
13.
Bacolod M, Heissel J, Shen YC. Spatial analysis of access to psychiatrists for US military personnel and their families. JAMA Netw Open. 2023;6(1):e2249314.
14.
Cantor JH, Tong PK. Geographical access to specialized behavioral health treatment programs for U.S. active duty service members and military families from military installations. Prev Med Reports. 2023;34:102267.
15.
Borah E, Fina B. Military spouses speak up: a qualitative study of military and Veteran spouses’ perspectives. J Fam Soc Work. 2017;20(2):144–61.
16.
Sharp ML, Fear NT, Rona RJ, et al. Stigma as a barrier to seeking health care among military personnel with mental health problems. Epidemiol Rev. 2015;37(1):144–62.
17.
Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351(1):13–22.
18.
Burke J, Miller AR. The effects of job relocation on spousal careers: evidence from military change of station moves. Econ Inq. 2018;56(2):1261–77.
19.
Castaneda LW, Harrell MC. Military spouse employment. Armed Forces Soc. 2008;34(3):389–12.
20.
Ben-Zeev D, Corrigan PW, Britt TW, Langford L. Stigma of mental illness and service use in the military. J Ment Heal. 2012;21(3):264–73.
21.
Michalopoulou LE, Welsh JA, Perkins DF, Ormsby L. Stigma and mental health service utilization in military personnel: A review of the literature. Mil Behav Heal. 2017;5(1):12–25.
22.
Seagle ES, Xu J, Edwards N, McComb SA. Social networking, social support, and well-being for the military spouse. J Nurse Pract. 2021;17(5):600–4.
23.
Donoho CJ, Riviere LA, Adler AB. The association of deployment-related mental health, community support, and spouse stress in military couples. Mil Behav Heal. 2017;5(2):109–16.
24.
Lennon MC, Rosenfield S. Women and mental health: the interaction of job and family conditions. J Health Soc Behav. 1992;33(4):316–27. https://www.jstor.org/stable/2137311
25.
Barnett RC, Hyde JS. Women, men, work, and family: an expansionist theory. Am Psychol. 2001;56(10):781–96.
26.
Corry NH, Radakrishnan S, Williams CS, et al. Association of military life experiences and health indicators among military spouses. BMC Public Health. 2019;19(1):1–14.
27.
Woodall KA, Richardson SM, Pflieger JC, et al. Influence of work and life stressors on marital quality among dual and nondual military couples. J Fam Issues. 2020;4(11):2045–64.
28.
Kim PY, Britt TW, Klocko RP, et al. Stigma, negative attitudes about treatment, and utilization of mental health care among soldiers. Mil Psychol. 2011;23(1):65–81.
29.
Kroenke K, Strine TW, Spitzer RL, et al. The PHQ-8 as a measure of current depression in the general population. J Affect Disord. 2009;114(1–3):163–73.
30.
Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder. Arch Intern Med. 2006;166(10):1092.
31.
Ruggiero KJ, Del Ben K, Scotti JR, Rabalais AE. Psychometric properties of the PTSD checklist-civilian version. J Trauma Stress. 2003;16(5):495–502.
32.
Kroenke K, Spitzer RL, Williams JBW, Löwe B. The patient health questionnaire somatic, anxiety, and depressive symptom scales: a systematic review. Gen Hosp Psychiatry. 2010;32(4):345–59.
33.
Wilkins KC, Lang AJ, Norman SB. Synthesis of the psychometric properties of the PTSD checklist (PCL) military, civilian, and specific versions. Depress Anxiety. 2011;28(7):596.
34.
Walker EA, Newman E, Dobie DJ, et al. Validation of the PTSD checklist in an HMO sample of women. Gen Hosp Psychiatry. 2002;24(6):375–80.
35.
Hoge CW, Grossman SH, Auchterlonie JL, et al. PTSD treatment for soldiers after combat deployment: low utilization of mental health care and reasons for dropout. Psychiatr Serv. 2014;65(8):997–1004.
36.
Long JS, Freese J. Regression models for categorical outcomes using STATA. 3rd ed. Texas: Stata Press; 2005. Available from: https://www.scholars.northwestern.edu/en/publications/regression-models-for-categorical-outcomes-using-stata
37.
StataCorp. Factor analysis STATA annotated output. College Station (TX): StataCorp.
38.
Vatcheva K, Lee M. Multicollinearity in regression analyses conducted in epidemiologic studies. Epidemiol Open Access. 2016;6(2).
39.
Howard MC. A review of exploratory factor analysis decisions and overview of current practices: what we are doing and how can we improve? Int J Hum Comput Interact. 2016;32(1):51–62.
40.
Britt TW, Greene-Shortridge TM, Brink S, et al. Perceived stigma and barriers to care for psychological treatment: implications for reactions to stressors in different contexts. J Soc Clin Psychol. 2008;27(4):317–35.
41.
Britt TW, Jennings KS, Cheung JH, et al. The role of different stigma perceptions in treatment seeking and dropout among active duty military personnel. Psychiatr Rehabil J. 2015;38(2):142–9.
42.
U.S. Department of Defense Health Board Task Force on Mental Health. An achievable vision: report of the Department of Defense Task Force on Mental Health [Internet]. Falls Church (VA): U.S. Department of Defense; 2007 [cited 2021 May 11]. Available from: https://apps.dtic.mil/sti/pdfs/ADA469411.pdf
43.
Lester P, Mogil C, Saltzman W, et al. Families overcoming under stress: implementing family centered prevention for military families facing wartime deployments and combat operational stress. Mil Med. 2011;176(1):19–25.
44.
Lester P, Stein JA, Saltzman W, et al. Psychological health of military children: longitudinal evaluation of a family-centered prevention program to enhance family resilience. Mil Med. 2013;178(8):838–45.
45.
Mogil C, Hajal N, Garcia E, et al. FOCUS for early childhood: a virtual home visiting program for military families with young children. Contemp Fam Ther. 2015;37(3):199–208.
46.
Muzik M, Schmicker M, Alfafara E, Dayton C, Schuster M, Rosenblum K. Predictors of treatment engagement to the parenting intervention mom power among Caucasian and African American mothers. J Soc Serv Res. 2014;40(5):662–80.
47.
Cohen L, Schwartz N, Guth A, Kiss A, Warner E. User survey of Nanny Angel network, a free childcare service for mothers with cancer. Curr Oncol. 2017;24(4):220–27.
48.
Rauschenberg C, Schick A, Hirjak D, et al. Evidence synthesis of digital interventions to mitigate the negative impact of the COVID-19 pandemic on public mental health: rapid meta-review. J Med Internet Res. 2021;23(3):e23365.
49.
Moreau JL, Cordasco KM, Young AS, et al. The use of telemental health to meet the mental health needs of women using Department of Veterans Affairs services. Women’s Heal Issues. 2018;28(2):181–7.

Information & Authors

Information

Published In

Go to Journal of Military, Veteran and Family Health
Journal of Military, Veteran and Family Health
Volume 10Number 5November 2024
Pages: 152 - 162

History

Received: 16 June 2023
Revision received: 1 April 2024
Accepted: 17 April 2024
Published in print: November 2024
Published online: 21 November 2024

Key Words:

  1. barriers to care
  2. military spouses
  3. mental health
  4. perceived stigma
  5. active duty
  6. U.S. Army

Mots-clés : 

  1. obstacles aux soins
  2. conjoint(e)s des militaires
  3. santé mentale
  4. stigmatisation perçue
  5. service actif
  6. armée américaine

Authors

Affiliations

Jessica R. Dodge
Biography: Jessica R. Dodge, MPH, LLMSW, PhD, is currently a research health scientist at the Center for Health Equity Research and Promotion at the Pittsburgh VA Medical Center. Her work centres on providing equitable care to military families, including research into understanding the social determinants of health for military families and new therapy techniques, implementing evidence-based practices, and evaluating current family programs.
Center for Health Equity Research and Promotion, Pittsburgh Veterans Affairs Hospital, Pittsburgh, Pennsylvania, United States
Kathrine S. Sullivan
Biography: Kathrine S. Sullivan, PhD, is Associate Professor at New York University’s Silver School of Social Work. She received her PhD from the University of Southern California’s Suzanne Dworak-Peck School of Social Work. Her work uses quantitative and qualitative methods to explore the impact of trauma and other risk exposures on family process and mental health outcomes, primarily among the families of service members and Veterans.
Silver School of Social Work, New York University, New York, New York, United States
Whitney Wortham
Biography: Whitney Wortham, MSW, MPH, is a third-year PhD student at New York University’s Silver School of Social Work. Her research interests include mental health services research and implementing evidence-based practices for families. Her current work centres on understanding factors impacting parent and caregiver access to mental health services. Wortham led federally funded projects promoting access to behavioural health services and trauma-specific interventions for children and practised as a caseworker in community settings.
Silver School of Social Work, New York University, New York, New York, United States
Katie Nugent
Biography: Katie Nugent, PhD, is a behavioural health epidemiologist in the Military Psychiatry Department at the Walter Reed Army Institute of Research and works to improve public health. Currently, she investigates topics related to health optimization, behavioural health problem prevention and management, and behavioural health service use in active duty military populations and their family members. This includes investigations of predictors of behavioural health symptoms and receipt of care. She also develops interventions for soldiers, leaders, and medics to optimize performance and prevent, identify, and manage behavioural health problems. In addition, Nugent develops interventions for behavioural health providers to facilitate appropriate treatment.
Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States
Carl A. Castro
Biography: Col. (retd) Carl A. Castro, PhD, is Professor and Director of the Military and Veteran Programs at the Suzanne Dworak-Peck School of Social Work at the University of Southern California. Castro is one of the leading military health theorists in the world today.
Center for Innovation and Research on Veterans and Military Families, University of Southern California, Los Angeles, California, United States
Lyndon A. Riviere
Biography: Lyndon A. Riviere, PhD, is a sociologist whose research focuses on soldier mental and physical health, intimate relationship functioning, military spouse well-being, financial hardship, and social determinants of health. He works as a research scientist in the Military Psychiatry Branch of the Center for Military Psychiatry & Neuroscience at Walter Reed Army Institute of Research (WRAIR). He is the principal investigator of several studies focused on characterizing soldier well-being and is a member of the WRAIR Institutional Research Board.
Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States

Notes

Correspondence should be addressed to Jessica Dodge at Center for Health Equity Research and Promotion, Health Services Research and Development, VA Pittsburgh Healthcare System, University Drive (151C), Building 30, Pittsburgh, Pennsylvania, United States, 15240-1001. Telephone: 734-845-3609. Email: [email protected].

Contributors

Conceptualization: JR Dodge, KS Sullivan, and CA Castro
Methodology: JR Dodge, K Nugent, and LA Riviere
Formal Analysis: JR Dodge
Data Curation: LA Riviere
Writing — Original Draft: JR Dodge, KS Sullivan, W Wortham, and K Nugent
Writing — Review & Editing: JR Dodge, KS Sullivan, CA Castro, and LA Riviere
Supervision: CA Castro

Competing Interests

Carl A. Castro is a member of the North Atlantic Treaty Organization and maintained a data support agreement with the Walter Reed Army Institute of Research to use the data and share with students.

Funding

This research was conducted during Dr. Dodge’s PhD program as part of her dissertation. Her dissertation was funded by the Suzanne Dworak-Peck School of Social Work.

Ethics Approval

This study was approved by the Walter Reed Institute of Army Research in Silver Springs, Maryland, United Stats, in 2012.

Informed Consent

N/A

Metrics & Citations

Metrics

VIEW ALL METRICS
VIEW ALL METRICS

Related Content

Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.

Format





Download article citation data for:
DodgeJessica R., SullivanKathrine S., WorthamWhitney, NugentKatie, CastroCarl A., and RiviereLyndon A.
Journal of Military, Veteran and Family Health 2024 10:5, 152-162

View Options

View options

PDF

View PDF

EPUB

View EPUB

Restore your content access

Enter your email address to restore your content access:

Note: This functionality works only for purchases done as a guest. If you already have an account, log in to access the content to which you are entitled.

Figures

Tables

Media

Share

Share

Copy the content Link

Share on social media

About Cookies On This Site

We use cookies to improve user experience on our website and measure the impact of our content.

Learn more

×