How Do Somatic Symptoms and Barriers to Care Affect Mental Health Service Use for Veterans with PTSD?

 

Abstract

Background: Military veterans demonstrate increased risk relative to civilian populations for mental health disorders such as posttraumatic stress disorder (PTSD), which is associated with poor outcomes including risky and suicidal behavior. Among veterans, PTSD is also associated with more somatic complaints than any other mental illness, and veterans with a PTSD diagnosis use more medical services than those with any other mental health or medical diagnosis. Veterans face significant barriers to obtaining mental health care, but there is a substantial gap in the literature related to differences in type and function of perceived barriers to care after transition from active duty to veteran status. This study investigates relationships between PTSD symptoms, somatic complaints, perceived barriers to care, and veterans’ medical and mental health service use to inform efforts at outreach and engagement for veterans with PTSD.

Methods: Data for these analyses were drawn from the Chicago Veterans Survey, completed between August 2015 and March 2016 by 1,264 veterans. Data were collected using multi-pronged convenience sampling to reach both VA connected and non-connected veterans. PTSD was measured using the PCL-5, which assess symptoms across the four DSM-V PTSD subscales. Somatic symptoms were measured with the PHQ-15, which assesses the presence and severity of somatic complaints. Barriers to mental health treatment were measured using a list of perceived internal and external obstacles to care. Mental health and medical care were measured using two dichotomous items capturing these dimensions of service use in the previous 12 months.

Results: A structural equation modeling approach was used to investigate relationships between study variables. Results indicated a good fit to the data, with c²(133, N=849)=327.66, p<.001, RMSEA=.037, CFI= 0.96, TLI=0.95. PTSD (γ= 0.46, p<0.001) was more strongly associated with mental health service use than internal barriers (β= -0.30, p<0.001). In addition, somatic symptoms (γ= 0.44, p<0.001) were more strongly associated with medical service use than external barriers (β= -0.23, p<0.01). Findings showed a strong direct effect of PTSD on somatic symptoms (γ= 0.62, p<0.001), internal barriers (γ = -0.11, p<0.05), external barriers (γ = 0.28, p<0.001), and mental health service use (γ = 0.46, p<0.01). Additional direct and indirect effects of PTSD and somatic symptoms on endogenous variables are discussed.

Implications: The proposed study contributes to ameliorating a substantial problem for researchers and clinicians interested in improving outcomes for veterans: only a small minority of veterans with PTSD symptoms seek mental health services. Study findings have the potential to elucidate the differential impact of psychological and somatic dimensions of PTSD symptomology on barriers to care and mental health and medical service use. Findings can be used to inform efforts at prevention and intervention aimed at improving outreach and engagement with veterans’ with PTSD symptoms who may currently be untreated or undertreated. Recommendations include PTSD screening for veterans presenting with somatic symptoms in medical contexts and ongoing assessment of barriers to care at multiple time points across service members’ trajectory from active duty to veteran status.