Enhancing Mental Health Services for U.S. Military Personnel: A Review of Current Practices ()
1. Introduction
The U.S. military plays a vital role in defending the nation’s security and interests, both at home and abroad. However, the unique demands and experiences of military service can have significant and far-reaching impacts on the mental health and well-being of service members. Military personnel are exposed to a wide range of profound stressors, including direct combat exposure, deployment-related trauma, such as witnessing or experiencing violence, family and household challenges like separation from loved ones and reintegration difficulties, and the trauma of military sexual assault, all of which can contribute to the development of mental health disorders such as depression, anxiety, post-traumatic stress, and substance abuse. Furthermore, the constant state of combat readiness and the ever-present threat of harm can also create a pervasive sense of danger, leading to complex physiological and psychological symptoms that further exacerbate these mental health concerns. Additionally, the families of service members are also significantly affected; as the degree of hardship and negative consequences often rises with the service member’s exposure to traumatic or life-altering experiences, there is an increased risk of psychological disorders among military spouses and children (Waitzkin et al., 2018).
Despite the clear need for comprehensive mental health support, military personnel often face significant barriers that impede their ability to access and utilize these critical services. Factors such as the perceived stigma associated with seeking mental health care, concerns about the potential negative impact on military careers and confidentiality, and difficulties integrating care across the military and civilian health care systems are just a few of the complex factors that can hinder service members from seeking and receiving the mental health support they desperately require. Research has shown that a substantial number of active-duty military personnel seek mental health services outside the military, often due to these deep-rooted concerns about confidentiality and the potential impact on their military careers. This highlights the urgent need for a comprehensive, integrated approach to mental health care that directly addresses the unique needs and worries of this population. Overcoming these systemic barriers and providing accessible, confidential, and effective mental health services is crucial for supporting the overall well-being, resilience, and readiness of U.S. military personnel.
Military personnel’s mental health needs surpass those of civilians, due to specialized psychiatrist care for PTSD, depression, or suicidal ideation. TRICARE ensures insurance coverage for mental health services received at military facilities without costs to the active-duty service members, while civilian care is circumstantial, contingent on a willingness to accept TRICARE. Despite higher mental health needs, a shortage of mental health resources in some areas significantly affects service members, resulting in an actual usage of available care that does not always align with the needs of service members. This discrepancy highlights the necessity of understanding the role of military and civilian psychiatric capacities in influencing behavioral health service engagement.
Emerging studies have shown varied behaviors influenced by external environmental factors. One study examined 1,958,205 unique service members across the armed forces between January 1, 2016, and September 30, 2020. Data was obtained through the Defense Health Agency, and monthly psychiatric information was collected from various health and census systems. The study observed notable disparities: 13% of service members had no access to military facility psychiatrists within a reasonable distance, and 66% resided in psychiatrist shortage areas (Shen et al., 2023). Among the active-duty population, 33% had at least one visit to any mental health care provider during the studied timeframe, reflecting various demographic trends. The investigated data illuminated a decisive reliance on military treatment facilities for mental health services and pointed out implications for future resource allocation strategies, including possibly redirecting military resources towards substantial community needs while enhancing partnerships with civilian health infrastructures (Shen et al., 2023).
To address these challenges, the Department of Defense and other stakeholders have implemented a range of initiatives and programs aimed at enhancing the availability, accessibility, and quality of mental health services for active duty and veteran military personnel, as well as their families. These efforts include mental health training during basic training to teach service members cognitive-behavioral skills for preventing and managing mental health symptoms, as well as expanding the use of embedded mental health providers within military units to improve the integration of mental health care and reduce barriers to access. Additionally, the military provides a comprehensive range of mental health services, such as inpatient and outpatient care, telehealth and online self-help programs, peer support, and specialized programs for issues like post-traumatic stress and military sexual trauma. However, research suggests that less than half of affected service members receive the necessary care, and significant barriers to accessing and utilizing these services remain.
This paper aims to provide a comprehensive review of the current state of mental health services for U.S. military personnel. By examining available services, evaluating their effectiveness, identifying barriers to care, and exploring innovative solutions, this review seeks to highlight the gaps in the system and offer actionable recommendations to improve the mental health care infrastructure.
2. Methods
Articles that investigated the mental health of U.S. military service members, current treatment modalities and barriers to access were included in this comprehensive review. Furthermore, articles were selected based on their relevance and applicability to the review topic. Studies were identified on PubMed, Military Medicine, and Cochrane Library that were published in English and in peer-reviewed journals by using the keywords “mental health”, “U.S. military”, “barriers” and “treatments”. Inclusion criteria were articles published in 2015 with a study population that focused exclusively on behavioral health and U.S. military service members. Exclusion criteria were articles published before 2015 that were not focused on behavioral health or included U.S. military service members as the study population.
3. Review of Literature
The U.S. military provides a range of mental health services aimed at supporting active-duty service members and veterans. These services are administered by the Department of Defense (DoD) and the Veterans Administration (VA) and include counseling, psychiatric care, and crisis intervention services. The DoD operates several specialized mental health programs, such as the Military and Family Life Counseling Program (MFLC), which provides short-term, non-medical counseling services to active-duty service members and their families. These services provide confidential counseling and comprehensive mental health support to address issues such as stress, depression, anxiety, and relationship problems. The VA provides mental health services to veterans and includes a network of inpatient and outpatient programs. VA facilities offer psychotherapy, medication management, and specialized treatment programs such as the PTSD Residential Rehabilitation Program (PRRP), which provides intensive, trauma-focused care for veterans suffering from PTSD. Additionally, telehealth services have been integrated into the military’s mental health care system, providing remote mental health support for service members, particularly those stationed in remote areas or deployed overseas. Telehealth has expanded the accessibility of mental health care, allowing service members to connect with providers via secure video calls, phone consultations, and online counseling sessions. This expansion has proven especially valuable in enhancing service member access to mental health services during deployments or in areas with limited local providers.
The U.S. Military Health System (MHS) pioneered the integration of telehealth technologies in deployed settings as early as the early 1990s, demonstrating its capability to deliver medical care remotely. However, the system has encountered significant challenges overseas and has struggled to implement telehealth solutions in non-deployed environments precisely due to both policy restrictions and technological limitations. Telehealth was first tested during critical deployments in the late 1980s and early 1990s, most notably during humanitarian missions in Somalia and multinational operations in the Balkan conflicts (Madsen et al., 2023). These early implementations set the groundwork for telehealth’s role in enhancing wartime medical care. One primary example of this was the internet protocol-based teleconferencing system, Web Real-Time Communications (WebRTC) system that enables secure connections to service members’ personal mobile devices, even outside of the DoD network. Furthermore, in conjunction with the utilization of the Vidyo platform, the WebRTC systems demonstrated a feasible option for overcoming challenges due to their ability to meet stringent security standards and to provide compatibility with iOS and Android mobile operating systems (Little et al., 2021). Vidyo was further integrated with a mobile application to create a comprehensive solution called Mobile Connect. The integration of Mobile Connect demonstrated that desktop video teleconferencing, from military computers to personal mobile devices, is technically feasible while maintaining required security protocols. Nevertheless, despite the significant technological accomplishments demonstrated through this project, the operationalization of the Mobile Connect system faced considerable hurdles, including disparate network configurations and ongoing software updates that hindered consistent connectivity and user experience (Little et al., 2021). Despite robust telehealth capabilities, these current capabilities lag behind the Veterans Health Administration (VHA) and various civilian health care systems. This deficiency is primarily attributed to persistent technical and policy obstacles, such as limited integration of telehealth technologies, inadequate funding, and resistance to change among medical personnel.
One of the main obstacles to effective mental health care in the military is the presence of various barriers that prevent service members from initiating or continuing treatment. Studies, such as the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), have identified three main categories of barriers: perceived need, structural barriers, and attitudinal barriers (Naifeh et al., 2017). The Army STARRS study utilized a representative sample of 5428 non-deployed Army Soldiers and found that a significant portion of service members –69.8% of those who never sought treatment—did not perceive a need for mental health care (Naifeh et al., 2017). Among those who did perceive a need, 80.7% cited attitudinal barriers, such as skepticism about the effectiveness of treatment, while 62.7% pointed to structural issues, such as lack of access or long wait times (Naifeh et al., 2017). This disconnect between perceived need and actual treatment is a critical factor in addressing the mental health needs of service members.
While the Army STARRS study highlighted that soldiers have a perceived skepticism regarding the necessity of treatment, other studies have highlighted similar barriers to care. A multisite project was conducted to identify the barriers that hinder the implementation of prolonged exposure therapy—a recognized and effective treatment for PTSD—across eight Military Treatment Facilities (MTFs) and to propose solutions for enhancing its use (McLean et al., 2022). Data was collected from eight MTFs to assess the needs, incorporating clinic administrative data and conducting interviews. The data identified that all eight sites experienced time-related challenges, including an inability to provide weekly psychotherapy sessions due to high patient-to-provider ratios and long appointment wait times, ranging from 2 to 6 weeks (McLean et al., 2022). Every site also reported provider-related challenges, notably a lack of confidence among providers in implementing prolonged exposure therapy, particularly with complex cases. Six out of the eight sites indicated inconsistent patient education regarding PTSD treatment options, where patients were often matched with providers irrespective of the specific training these providers had (McLean et al., 2022). Six sites faced difficulties with scheduling, specifically the management of the 90-minute session format for prolonged exposure therapy within high-demand environments, compounded by scheduling challenges due to templates and procedures for modifying schedules (McLean et al., 2022).
Structural barriers included financial constraints and logistical challenges in accessing care. Respondents with severe role impairment reported higher incidences of structural barriers compared to those with less impairment (Naifeh et al., 2017). Research conducted by the Military Issues Work Group (MIWG) investigated challenges faced by military service members and their beneficiaries, particularly those in rural and remote areas. The study reported that approximately 1.3 million Department of Defense (DoD) beneficiaries are at risk of being over 30 minutes away from mental health care, which highlighted significant barriers to access, impacting their care-seeking behavior and overall well-being (Naifeh et al., 2017). Despite advancements and focus on improving mental health services, the availability and quality of these services remain inconsistent, particularly in rural regions. These disparities highlight the effort to leverage technology to improve accessibility and enhance engagement in mental health care. It was further identified that while technology offers hopeful avenues for bridging these gaps, other significant barriers remain, including the need for behavioral change among providers and service members in utilizing these new technologies effectively. In response to the findings, the MIWG emphasized the need for tele-mental health technologies, such as mobile applications, to bridge these access gaps (McGraw et al., 2019).
Attitudinal barriers are another major challenge to mental health care in the military, with notable preferences for self-reliance and stigma surrounding mental health issues were also prevalent. Military culture traditionally values toughness, self-reliance, and perseverance, and seeking mental health support is often seen as a sign of weakness. This stigma discourages many service members from seeking the help they need, particularly when mental health issues could impact their career progression or security clearance. Data collected from the Psychiatric Continuity Services Clinic at Walter Reed National Military Medical Center over six months further supports this (Zumwalde et al., 2023). Various behavioral health assessments were employed to evaluate mental health status and to understand how it correlated with perceptions of stigma through the Military Stigma Scale (MSS) and treatment engagement. The findings from this study revealed a significant correlation between non-white ethnicity and higher levels of reported stigma, particularly among service members exhibiting symptoms of PTSD (Zumwalde et al., 2023). This demographic often faces compounded stigma from within the military community, and the broader community, creating barriers to seeking treatment. Furthermore, recommendations for addressing stigma in a treatment setting included cultural competency training for practitioners and providers, outreach programs among service members to normalize mental health discussions, and establishing support systems that convey confidentiality and safety (Zumwalde et al., 2023).
4. Discussion
The objective of this comprehensive review was to assess the current state of mental health services for U.S. military personnel, evaluate their effectiveness, identify barriers to care, and explore actional solutions to improve the current infrastructure. One key initiative in military healthcare is Holistic Health and Fitness (H2F), a comprehensive soldier readiness system designed to promote and sustain positive personal health behaviors. This system represents a fundamental shift from a traditional healthcare approach towards a holistic “System for Health”, prioritizing prevention and personal wellness. The H2F approach emphasizes a person-centered model of care, shifting away from the reactive, illness-focused system to one that actively engages individuals in their health choices, promoting long-term health maintenance. Essential components of this system include physical activity, balanced nutrition, adequate sleep, and tobacco use cessation, which are foundational to overall well-being. This transition underscores the need for healthcare to address lifestyle choices proactively, utilizing education, incentives, and technology to empower individuals to take ownership of their health. Mobile health applications, wearable devices, and virtual communities are integral to this model, offering personalized health messaging and monitoring tools that help service members track their physical activity, nutrition, and sleep patterns.
Transitioning to a person-centric healthcare model requires a drastic rethinking of how health is prioritized, moving away from a focus on costs and clinical metrics to prioritizing health maintenance and preventive strategies tailored to individual needs. Rather than just managing symptoms, health care must address lifestyle choices proactively while encouraging individuals to take ownership of their health. This goal can be achieved by developing personalized health plans that recognize individuals’ unique needs and preferences and foster sustainability in health improvement efforts. Technological advancements play a vital role in health promotion, with mobile health apps and wearable devices serving as key tools for supporting lifestyle changes through personalized health messaging. Monitoring physical activity, nutrition, and sleep patterns helps individuals adhere to their health goals and identify areas for improvement. In addition, engaging virtual communities and innovative gaming platforms provide motivation and encourage commitment to healthier behaviors. Furthermore, initiatives like “Operation Live Well” focus on enhancing the health of specific populations, such as military personnel, by increasing access to nutritious food and encouraging physical activity, reinforcing the importance of sustainable health behaviors supported by consistent engagement from healthcare providers and community systems. Sustainable health behaviors require ongoing support from health care providers and community systems, empowering individuals to take charge of their daily health choices. By fostering consistent daily habits, significant improvements in overall health, well-being, and quality of life can be achieved (Teyhen et al., 2018).
In the context of mental health, Mental Health Specialists (MHS) play an indispensable role in supporting service members, particularly in high-stress environments where combat stress and other operational pressures can exacerbate mental health issues. MHS undergoes 20 weeks of Advanced Individual Training (AIT), but there is growing recognition that additional training is needed to address the increasingly complex mental health challenges within military settings. To address this gap, the U.S. Army Reserve piloted a more collaborative and rigorous training plan where MHS did a 9-day training rotation in the Psychiatric Emergency Service at Denver Health, a facility specifically designated to handle high-acuity behavioral emergencies with cases ranging from substance abuse crises to severe psychiatric disorders (Simpson et al., 2019). This joint military-civilian collaboration was proposed to enhance MHS training beyond their mandatory training to improve their preparedness for addressing the increasing complexities of mental health issues within the military context. A Memorandum of Understanding was established to outline the roles, responsibilities, and expectations for military and civilian staff, fostering a collaborative training environment focused on shared learning and outcome improvement. Comprehensive evaluation methods, such as surveys and retrospective chart reviews, were employed to assess the education experience of MHS and gauge civilian staff perceptions of the partnership. The results indicated overwhelmingly positive feedback, with 83% of MHS stating their training experience was rated as “very good or excellent” while 50% of staff members reported an improved perception of the U.S. Army Reserve soldiers (Simpson et al., 2019). Furthermore, the data revealed that MHS reported high confidence in managing psychiatric presentations, particularly in areas vital to military practice, such as crisis intervention and trauma-informed care. This initiative exemplified the first successful partnership dedicated to training Army Mental Health Specialists. It provided relevant clinical exposure while fostering interprofessional relationships vital for effective mental health care delivery. However, the program also highlighted areas for improvement. For example, while the training provided valuable clinical exposure, there were challenges related to the efficiency of clinical service delivery and gaps in addressing specific conditions commonly encountered in military settings, such as Post-Traumatic Stress Disorder (PTSD). These findings underscore the need for continuous refinement of MHS training programs to better prepare them for the unique psychological demands of military service. This collaborative training model also demonstrates the potential benefits of military-civilian partnerships, particularly in improving the preparedness of mental health professionals for complex mental health crises.
5. Conclusion
Mental health challenges among U.S. military personnel have significant implications for both individual service members and overall military readiness. While current mental health services have made strides, there are critical gaps in accessibility, cultural attitudes, and provider availability that continue to hinder optimal care. Addressing these challenges requires a comprehensive, multi-pronged approach that encompasses prevention, early intervention, and treatment.
One of the primary barriers to effective mental health care is accessibility. Service members often face significant obstacles in accessing timely and adequate mental health services, particularly in remote or deployed settings. Although the Department of Defense (DoD) has made considerable progress in integrating telehealth technologies to bridge geographical gaps, the full potential of these innovations has not been realized due to policy restrictions, technological limitations, and resistance to change among both providers and service members. Expanding telehealth services to overcome these barriers is essential, but it requires the resolution of logistical and policy-related challenges to ensure its seamless integration across all military settings. In addition to telehealth, the military must prioritize expanding the availability of qualified mental health professionals. This includes not only increasing recruitment but also improving the training of Mental Health Specialists (MHS) to handle the complexities of military-specific mental health issues.
Cultural stigma surrounding mental health care remains a significant challenge in the military. Military culture traditionally values toughness, self-reliance, and resilience, leading to a reluctance among service members to seek help for mental health issues due to concerns about perceived weakness or career repercussions. To combat this stigma, proactive mental health programs are essential. These programs should focus on normalizing mental health support, integrating mental health care more fully into military life, and ensuring that seeking help is seen as a sign of strength rather than weakness. Initiatives aimed at educating both service members and leaders about the importance of mental health and wellness are critical in shifting these cultural perceptions. By creating a culture that prioritizes mental well-being, the military can foster a more supportive environment where service members feel empowered to seek help without fear of stigma or career harm. In addition to expanding access and reducing stigma, training plays a pivotal role in improving mental health care within the military. Enhancing the training of MHS, as demonstrated by successful programs like the U.S. Army Reserve’s collaboration with Denver Health, can improve their preparedness to address complex mental health issues effectively. The program’s successful pilot underscores the importance of interprofessional education and suggests that further efforts should be made to ensure that MHS receives the most relevant and comprehensive training. By integrating civilian expertise into military training programs, the military can enhance the quality of care provided to service members, particularly in addressing the unique challenges faced in combat and other high-stress environments.
Finally, ongoing research, evaluation, and adaptation of mental health programs are crucial to ensuring that services evolve to meet the changing needs of service members. As the nature of military service and the stressors faced by personnel evolve, mental health care initiatives must also adapt to remain effective. Continued research, evaluation, and refinement of mental health initiatives will be essential to addressing the evolving needs of the military community and delivering the high-quality, accessible care that is so vital for those who serve our nation. By implementing these strategies, the military can work to ensure that all personnel and their families have the resources and support they need to prioritize their mental well-being and resilience, ultimately enhancing the overall health and readiness of the force.
Acknowledgements
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The views expressed herein are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the U.S. Government.