The implications of this work are three-fold. First, we present clear evidence that the main barrier to seeking help is anticipated public stigma, and therefore interventions aimed at reducing stigma in the military are important and timely. Stigma is learned and culturally specific and an important implication of this is that it may be unlearned [32
]. The US military have recently introduced a series of education programmes delivered in a group setting for soldiers and their families, which aim to decrease the stigma associated with seeking help for a mental health problem and encourages soldiers to seek assistance if they have symptoms ([33
], and have demonstrated in a randomised controlled trial that for those with high combat exposure there is a reduction in stigmatising beliefs post-intervention (compared with pre- intervention)[34
]; a version of the same tool is currently being trialled in the UK. A recent re-examination of the same barriers to care as were reported in Hoge's 2004 study has shown a substantial reduction in the perception of these barriers over the last four years, particularly with respect to the belief that personnel seeking help would be 'seen as weak' (emphasis has been made in education of the chain of command that 'help-seeking is a sign of strength') [28
], and this has been more recently confirmed by the Mental Health Advisory Team (VI) report which has showed a reduction in the endorsement of barriers to care statements over time [35
]. This is encouraging and suggests that interventions of this kind are capable of beginning to shift stigmatising beliefs and that culture change can be achieved. In the same study, Warner et al reported that the encouragement of friends and family was cited as the most important factor in overcoming barriers to care by Service personnel [28
]. Interventions designed to support and educate families are, therefore, a crucial adjuvant to the above, and more research is needed to determine how this can be achieved most effectively.
In addition to this, Greene-Shortridge et al [9
], drawing on Corrigan and Penn's model of methods to reduce stigma [36
], have suggested a series of measures worthy of consideration. Programmes which aim to promote contact with individuals who have a mental illness could be exploited in a military context by, for example, involving soldiers with PTSD who have been successfully treated in structured discussion and education within the unit, and indeed evaluations of such an initiative are currently underway in Canada where it has proved popular. Green-Shortridge et al [9
] also emphasise the importance of encouraging leaders to take an active role in identifying and assisting soldiers to receive mental health support; this may be of particular relevance since fears about leader's view of help-seeking was one of the most highly endorsed stigma statements in this study. Recent studies have shown that leaders in general, contrary to personnel's fears, take a positive attitude towards their staff seeking help [37
]. Leaders who make it clear to their subordinates that they endorse the notion that PTSD results from exposure to extreme stressors rather than individual weakness [9
], and that help-seeking is acceptable and a sign of maturity, are likely to be powerful agents of change and reduction in stigma [9
], and this is confirmed by recent work which has shown that positive leadership and higher unit cohesion reduces stigma and barriers to care, independent of any effect on the prevalence of mental health problems [38
]. There is also evidence that individuals who are referred for mental health treatment by the chain of command are much more likely to complete the course of treatment than those who self-refer, indicating that approval is an important catalyst for engagement with treatment [39
]. Peer-led schemes which aim to educate leaders in how to identify and signpost vulnerable individuals after a traumatic event such as Trauma Risk Management (TRiM) may well serve this purpose [40
]. An important caveat though is that any new interventions must be subjected to rigorous evaluation (for example, a randomised controlled trial) before they are introduced, as if they are ineffective, they may simply serve to medicalise distress without benefit.
As well as general interventions to reduce stigma in the still-serving military, we suggest that specific interventions are required to target those who are most vulnerable. Reservists in particular are experiencing practical barriers to receive of treatment, and therefore educating civilian employers and general practitioners about common mental health problems after deployment whilst emphasising the importance of providing guaranteed time off from work to consult without penalty is important.
In the UK, the care of veterans falls to the National Health Service after they leave the Armed Forces and we suggest again that outreach programmes which aim to educate primary and secondary care about common problems in the veteran population are important so that mental health problems can be identified and treated promptly in this vulnerable group. The stigma associated with consulting is reported to be less if the Service personnel can consult someone who has knowledge and expertise of military matters [28
], and hence the service charities have an important role to play in both providing care and in outreach and education of the NHS. Recent initiatives such as the recent MoD/NHS/Combat Stress Community Veteran Pilot Scheme aim to exploit these partnerships further, and are currently being evaluated.
Finally, we report that unwell personnel are the most likely to report barriers to care. This finding has important public health implications for the military as it suggests efforts to target stigmatising beliefs needs to be targeted toward those who are most unwell. Efforts such as outreach and formal education programmes to reduce the stigma of consulting, and clear unambiguous messages from the chain of command that personnel are actively encouraged to seek help targeted at high risk groups (such as those returning from operational duties) are important and timely.