It is regrettable in light of the availability of effective treatments that many PTSD sufferers wait years to decades before they seek professional help for their PTSD, if they seek it at all. Research identifying the determinants of PTSD treatment initiation among veterans is needed to inform interventions to promote appropriate treatment seeking.
To (1) identify barriers and facilitators to treatment initiation for PTSD; (2) compare barriers and facilitators among veterans who served in Operation Enduring Freedom or Iraqi Freedom (OEF/OIF) to those among veterans from the Vietnam era (VE); and (3) understand and develop a conceptual framework for future research and interventions on PTSD treatment initiation.
This was a qualitative study based on semi-structured individual interviews. We used a stratified purposeful sampling strategy to obtain a sample that varied on the key variables: treatment-seeking status (yes, no); gender, and for men, service era (OEF/OIF, VE). Participants described factors that either helped or hindered their treatment seeking for PTSD. Interviews were recorded, transcribed and analyzed using inductive analysis and the constant comparison method.
The sample consisted of 44 veterans seeking PTSD service connection, almost half of whom were in treatment for PTSD. Twenty-two were OEF/OIF and 19 were VE veterans. Three women served in the military after the VE but before OEF/OIF. Almost one third of the sample was female. Participants described factors that hindered their help-seeking, including trauma-related symptoms, their own values and priorities, treatment-discouraging beliefs, concerns about the VA, access barriers, and an invalidating post-trauma/post-deployment environment. Participants also described facilitators within themselves, the health care and disability systems, and their social networks. In some cases, facilitators located at the system and the social network levels of analysis led to treatment initiation despite individual-level barriers such as treatment discouraging-beliefs and values that conflicted with help-seeking. In general, VE veterans had more barriers and fewer facilitators than veterans returning from Iraq and Afghanistan. Lack of understanding of PTSD during the VE and negative homecoming experiences had an enduring and pronounced impact on help-seeking. In contrast, OEF/OIF veterans had more facilitators. Even OEF/OIF veterans who were not in treatment had a basic understanding of PTSD and services that many VE veterans lacked. OEF/OIF veterans also described strategies the military implemented to improve access and reduce stigma.
Socio-cultural and system-level factors play an important role in determining PTSD treatment initiation. Therefore, we propose a conceptual model of PTSD treatment initiation that includes social network, health-care and disability system, and post-trauma/post-deployment environmental determinants, as well as the individual level determinants of PTSD treatment initiation typically included in utilization studies. Findings also have implications for the development of interventions to promote timely help-seeking for PTSD. VA may need to tailor outreach strategies for veterans who do not have an extensive or supportive social network and who experienced post-trauma or post-deployment invalidation.
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