Culture provides the unwritten rules that inform and shape expected behaviors. To date, little research has been conducted into the attitudes or opinions that service personnel hold toward mental health issues. This article examines current literature and research into the recognition of mental health problems in the military and potential organizational barriers to care including stigma and the specific characteristics of a military culture such as the significant reliance on buddy support. We conclude that the barriers to care which operate in both military and civilian populations are not insignificant. Western militaries in fact currently face an uphill struggle to combat the substantial barriers to care that exist.

Military personnel are at a high risk of exposure to potentially traumatic events. As such, this makes tiiem an “atrisk group” who are vulnerable to suffering from psychological distress and mental health problems including depression, family violence, substance abuse, and post-traumatic stress disorder (PTSD), all of which are problems for the military services and a threat to occupational functionality.1 The impact of mental health on decision making is especially of significance given the high technology, fast-paced warfare of the 21st century, the battlefield which leaves little margin for error. Furthermore, many military forces have to cope with increasingly complicated conflicts with an ever decreasing number of soldiers available to fulfill these duties.2 Troops therefore need to function at peak efficiency and inefficiencies imposed by work stress and mental health problems may have very serious consequences.

Recent claims from soldiers and commanders inside the theaters of Iraq and Afghanistan have raised questions about the state of mental healtii in the U.K. military.4,5 This article attempts to explore the issue of military culture in relation to stress (traumatic or otiierwise) and examines how the military environment may exacerbate psychological problems because of barriers to care including stigma.

The Different Types of Stressors within a Military Environment

The potential of being exposed to traumatic stressors is an ever present issue for individuals who choose the military as their occupation. Furthermore, additional work-related stressors, such as length of deployment or exposure to adverse living condition, may exacerbate the effects of traumatic stress.3 In this section, relevant research on the two different types of stressors will be discussed.

Studies have shown that the degree of psychological trauma from operational duties is proportionally related to the type of warfare fought.6 One of the adverse outcomes of wartime trauma is PTSD. Rates of PTSD in combat veterans have been measured on numerous occasions and vary from 15 to 31%.7·8 These rates are in excess of the 2 to 3% prevalence of PTSD symptoms recorded in the U.K. general population.9 However, focusing on PTSD alone may not give the full picture of operationally induced psychological distress. For instance, it has been reported that up to 50% of Falkland War veterans have symptoms of PTSD even though they may not have sufficient or intense enough symptoms to warrant a formal diagnosis of PTSD.

Some of the variation in rates of PTSD and prevalence of traumatic stress symptoms may be accounted for by differences in study design. For instance, there are many types of instruments used to measure PTSD and many different ways of classifying military missions.11 Furthermore, questionnaires usually overestimate the prevalence of psychiatric conditions.12 Studies which use semistructured instruments such as the Clinician-Adniinistered PTSD Scale are likely to give a better estimate of the true prevalence figure. Studies also vary in their use of terminology and it is important to remember that suffering with PTSD symptoms does not always prevent individuals from working or having fulfilling social lives. Symptoms are not the same as disorder, altiiough it would be foolish to merely dismiss subdiagnostic symptoms as being irrelevant: they may well affect quality of life.

Aside from operationally related traumatic stress, there are numerous other work-related stressors which significantly affect the lives of service personnel. Pflanz et al.3 investigated sources of stress and their prevalence in the U.S. military. Significant work stress was reported by 26% of troops and another 15% described significant emotional distress related to work stressors. The study revealed tiiat being in combat, exposure to heavy casualties, and unexpected deployments all correlated with increased levels of psychological distress.

Mental disorders, whether they are the result of traumatic or work stressors, appear to have had a significant impact on manpower and retention rates. Hoge et al.1 conducted a population-based analysis of hospitalizations occurring at U.S. military medical facilities between 1990 and 1999 among active duty personnel. Results showed that mental disorders were the leading cause of medical discharge among men and the second leading category among women, accounting for 13% of all hospitalizations. Overall, 23% of all inpatient bed days were attributed to mental disorders.