ARTICLE CRITIQUE

Attached below is the article I have to critique. it has to follow the instructions.

 Answer the following questions that pertain to essential literature review elements:  

 1) What is the title of the article? Provide the citation for the article in APA format. 

2) Explain how you determined the credibility of the research provided. 

3)  What is the purpose of the article? 

4)  What is the hypothesis of the study? In other words, what claims do the authors make in the article? 

5) What variables (factors) are being looked? How are these factors assessed or measured in the article? 

6)bWhat type of research design is used in the study? What instruments or measures did the researchers use to collect data? 

7) Do you think the research in this article was conducted in an ethical manner? Why or why not?  

 Each question must be answered in at least 2-3 sentences, although you can write more if needed. Be sure to cite directly from the sample article in order to support your answers.

below is a guide for the grading rubric  

– Article: Title (APA) – Provides the article title and the citation in perfect APA format –

– Determination of Credibility –  Explains how the credibility of the research presented in the article was determined –

 – Article: Purpose – Describes the purpose of the article in adequate detail –

– Hypothesis/claims  – Description clearly identifies the claim(s) the authors make in the article –

– Variables – Description identifies the variables (factors) that are being looked at –

 -Research Design –  Clearly and accurately identifies and describes the research design that is used in the article –

– Ethics –  Explains whether or not the research in the article was conducted in an ethical manner  –

 – Writing Mechanics – Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy-to-read format –

Journal of Traumatic Stress
June 2014, 27,

307

–313

Mental Health Beliefs and Their Relationship With Treatment
Seeking Among U.S. OEF/OIF Veterans

Dawne Vogt,1,2 Annie B. Fox,1 and Brooke A. L. Di Leone1
1Women’s Health Sciences Division, National Center for Posttraumatic Stress Disorder, VA Boston Healthcare System, Boston,

Massachusetts, USA
2Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA

Many veterans who would benefit from mental health care do not seek treatment. The current study provided an in-depth examination of
mental health-related beliefs and their relationship with mental health and substance abuse service use in a national sample of 640 U.S.
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans. Both concerns about mental health stigma from others
and personal beliefs about mental illness and mental health treatment were examined. Data were weighted to adjust for oversampling of
women and nonresponse bias. Results revealed substantial variation in the nature of OEF/OIF veterans’ mental health beliefs, with greater
anticipated stigma in the workplace (M = 23.74) than from loved ones (M = 19.30), and stronger endorsement of negative beliefs related to
mental health treatment-seeking (M = 21.78) than either mental illness (M = 18.56) or mental health treatment (M = 20.34). As expected,
individuals with probable mental health problems reported more negative mental health-related beliefs than those without these conditions.
Scales addressing negative personal beliefs were related to lower likelihood of seeking care (ORs = 0.80–0.93), whereas scales addressing
anticipated stigma were not associated with service use. Findings can be applied to address factors that impede treatment seeking.

Recent research suggests that many veterans who might ben-
efit from mental health treatment do not seek care. For exam-
ple, in a large national survey of Operation Enduring Free-
dom/Operation Iraqi Freedom (OEF/OIF) veterans, nearly half
of those who screened positive for probable posttraumatic stress
disorder (PTSD) or major depression reported that they had not
received any mental health care in the previous year (Schell
& Marshall, 2008). Both beliefs about the extent to which one
will be stigmatized by others for experiencing a mental health
problem and personal beliefs about mental illness and men-
tal health treatment have been posited as key barriers to care
for this population (Vogt, Di Leone, Wang, Sayer, Pineles, &
Litz, 2014). The former category builds on Corrigan and col-
leagues’ extensive body of work on public stigma related to
mental illness (e.g., Corrigan, 2004; Corrigan & Rüsch, 2002),

This research was supported, in part, by a Department of Veterans Affairs
Health Sciences Research and Development Service grant (DHI 06-225-2;
Gender, Stigma, and Other Barriers to VHA Use for OEF/OIF Veterans; PI:
Dawne Vogt, PhD).

Note: Following completion of this manuscript, Dr. Di Leone relocated to the
Philadelphia VA Medical Center. Dr. Di Leone’s current affiliation is the Center
for Health Equity Research and Promotion, Philadelphia VA Medical Center.

Correspondence concerning this article should be addressed to Dawne Vogt,
National Center for PTSD (116B-3), VA Boston Healthcare System, 150 South
Huntington Avenue, Boston, MA 02130. E-mail: Dawne.Vogt@va.gov

Published 2014. This article is a US Government work and is in the public
domain in the USA. View this article online at wileyonlinelibrary.com
DOI: 10.1002/jts.21919

and is conceptualized as encompassing concerns about stigma
from loved ones, as well as concerns about stigma in the work-
place. Personal beliefs about mental illness and mental health
treatment, on the other hand, reflect the extent to which indi-
viduals have incorporated negative beliefs about mental illness,
the nature of mental health treatment, and the appropriateness
of seeking treatment for mental health problems into their own
personal belief systems (Vogt, 2011).

The emphasis on competence, confidence, and stoicism in the
military may make negative mental health beliefs an especially
salient barrier to care for both current and former military per-
sonnel (Nash, Silva, & Litz, 2009; Sayer et al., 2009). Indeed,
studies indicate that anticipated stigma is a commonly reported
barrier to care in military and veteran samples. For example,
in one study approximately one in three OEF/OIF veterans in
one study reported that they would be stigmatized by others for
seeking mental health treatment (Hoge et al., 2004), and fear
of being labeled with a mental health disorder was identified as
a concern for nearly three quarters of OIF veterans in another
study (Stecker, Fortney, Hamilton, & Ajzen, 2010).

Less is known about the extent to which negative personal
beliefs about mental illness and mental health treatment serve
as a barrier to treatment for military and veteran populations,
although accumulating evidence suggests that they are also a
concern. For example, among OEF/OIF veterans with men-
tal health problems, 44% indicated that seeking mental health
treatment would make them feel down on themselves (Elbogen
et al., 2013), and nearly one in five reported that mental health

307

308 Vogt, Fox, and Di Leone

treatment should only be sought as a last resort (Kim, Britt,
Klocko, Riviere, & Adler, 2011). Negative beliefs about mental
health treatment also appear to be common; one in four soldiers
in the latter study also reported that they do not trust mental
health professionals.

Although these mental health beliefs may serve as barriers
to care, most military and veteran studies to date have been
restricted to clinical samples with demonstrated mental health
problems, limiting the conclusions that can be drawn about the
extent to which these concerns are relevant for the larger pop-
ulation. A primary aim of the present study was to document
concerns about stigma and personal beliefs about mental ill-
ness and mental health treatment within a national sample of
OEF/OIF veterans. This population represents an ideal target for
such a study given that their potential exposure to stressful and
traumatic events in the warzone put them at risk for a variety of
mental health problems (Tanielian & Jaycox, 2008). In contrast
with prior research, which has primarily relied on convenience
samples and failed to consider the impact of nonresponse bias
on study findings, both sampling weights and nonresponse bias
weights were applied to produce results that would be optimally
representative of the larger OEF/OIF population.

A second aim of this study was to examine how mental health
beliefs differ for veterans with and without mental health prob-
lems. Prior studies indicate that OEF/OIF veterans with mental
health problems report more negative mental health beliefs than
those without mental health problems (e.g., Hoge et al., 2004).
We are not aware, however, of any research that has examined
the extent to which this finding holds across different men-
tal health belief domains and mental health conditions. Thus,
in the present study we examined how mental health beliefs
varied for OEF/OIF veterans with and without three common
mental health conditions, namely, PTSD, depression, and alco-
hol abuse.

Our final aim was to examine how mental health beliefs
are related to the use of mental health care among OEF/OIF
veterans with probable PTSD, depression, and alcohol abuse.
Findings from the military and veteran literature on the im-
pact of concerns about stigma on treatment seeking have been
mixed, with several recent studies suggesting that anticipated
stigma from others may be positively, rather than negatively,
associated with mental health service use (Olmsted et al., 2011;
Rosen et al., 2011; Stecker, Fortney, Hamilton, Sherbourne, &
Ajzen, 2010). In contrast, several recent studies suggest a key
role for personal beliefs about mental illness and mental health
treatment as a barrier to care (Brown, Creel, Engel, Herrell,
& Hoge, 2011; Kehle et al., 2010; Kim et al., 2011; Pietrzak
et al., 2009; Stecker et al., 2007; Sudom, Zamorski, & Garber,
2012). No studies to our knowledge, however, have provided an
in-depth examination of separate domains of personal beliefs
about mental illness and mental health treatment as predictors
of mental health service use.

We had several expectations for the study. We hypothesized
that participants would be more likely to report concerns about
stigma from others than to endorse negative mental health be-

liefs themselves. We also hypothesized that individuals with
probable PTSD, depression, and alcohol abuse would be more
likely to report both concerns about stigma from others and
negative personal beliefs about mental illness and mental health
treatment than individuals without these problems, but that only
personal mental health beliefs would be related to lower like-
lihood of seeking mental health services. We had no specific
hypotheses regarding differential associations for mental health
belief domains or mental health condition given the lack of
prior research on these topics. Because some individuals may
not endorse negative beliefs about mental illness and mental
health treatment due to social desirability concerns, social de-
sirability was included in all analyses of associations among
study variables. We also accounted for mental health condition
symptom severity in analyses examining predictors of service
use, given that individuals with more severe symptoms may be
more likely to both report negative mental health beliefs and to
seek treatment.

Method

Participants and Procedure

We surveyed a national sample of U.S. veterans who had experi-
enced a recent deployment to either Afghanistan (OEF) or Iraq
(OIF), and were separated from military service at the time of
the study. Names were randomly selected from a Defense Man-
power Data Center (DMDC) roster of all OEF/OIF veterans
who had returned from deployment between 2 and 4 years prior
to data collection (2007–2009). Women were oversampled to
allow for gender-stratified analyses (50% women; 50% men). A
modification of the Dillman, Smyth, and Christian (2009) mail
survey procedure was used for data collection. Specifically, we
first mailed potential participants the survey, an opt-out form,
and a $20 gift card. A reminder postcard was mailed 1 week
later, followed by a second mailing of the assessment package
to nonresponders 4 weeks after the reminder, another reminder
postcard 1 week after that, a final survey package 4 weeks later,
and a final reminder 1 week after that for a total of 11 weeks
from our initial approach. Of 2,950 potential participants, 460
could not be located and 17 responded to indicate that they were
ineligible for the study (i.e., not OEF/OIF veterans). Among
the remaining 2,473 individuals believed to have received the
survey, 707 returned completed surveys for a response rate of
28.6%. We compared survey responders to nonresponders on
demographic and military characteristics drawn from DMDC
administrative records data to explore the potential for nonre-
sponse bias. Although all differences except the comparison
based on Active Duty versus National Guard/Reservist status
were statistically significant for these large sample-size com-
parisons, effects were generally small, suggesting that they were
of little clinical significance. Specifically, differences between
responders and nonresponders were small with regard to gen-
der (Cramér’s ϕ = −.11), age (r = .19) race (Cramér’s ϕ =
−.041), military rank (Cramér’s V = 0.14), education (Cramér’s

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Mental Health Beliefs Among OEF/OIF Veterans 309

ϕ = .19), marital status (Cramér’s ϕ = −.07), military branch
(Cramér’s V = 0.08), and duty status (Cramér’s ϕ = .01).

For the present study, we limited the sample to only those
individuals who completed all stigma and personal belief mea-
sures (N = 640). The sample was composed of 56.7% women
and was primarily Caucasian (66.8%). The sample included
veterans from all service branches: Army (50.7%), Air Force
(23.2%), Navy (17.3%), and Marines (8.8%), and the major-
ity was deployed from Active Duty (78.5%). The mean age of
participants was 37.23 years (SD = 10.03).

Measures

Mental health beliefs were assessed with the Endorsed and An-
ticipated Stigma Inventory (EASI; Vogt et al., 2014). Concerns
about stigma from others were addressed with the following
scales: (a) Concerns about Stigma from Loved Ones, and (b)
Concerns about Stigma in the Workplace. Negative personal
beliefs about mental illness and mental health treatment were
addressed with the following scales: (a) Beliefs about Mental
Illness, (b) Beliefs about Mental Health Treatment, and (c) Be-
liefs about Treatment Seeking. Each scale includes eight items
that are framed as statements and rated using a 5-point Likert-
type response format from 1 = strongly disagree to 5 = strongly
agree, with a total possible range from 8 to 40. All scales were
scored so that higher scores reflected more negative beliefs.
Coefficient α for these scales ranged from .84 to .93 in the
current sample. Evidence is available for the internal consis-
tency reliability, content validity, convergent and discriminant
validity, and discriminative validity of EASI scales (Vogt et al.,
2014). In addition, confirmatory factor analysis results support
the proposed 5-factor structure of this inventory of scales (Vogt
et al., 2014).

To assess posttraumatic stress disorder (PTSD) symptom
severity related to stressful deployment experiences, we used
the 17-item PTSD Checklist-Military Version (PCL-M; Weath-
ers, Litz, Herman, Huska, & Keane, 1993). Coefficient α was
.97 in the current sample. All participants who had a score of
at least 50 (n = 125, 19.5% of total sample) were identified as
having probable PTSD (Tanielian & Jaycox, 2008).

Depression symptom severity was assessed with an adapted
version of the 7-item Beck Depression Inventory-Primary Care
(Beck, Steer, Ball, Ciervo, & Kabat, 1997). Each item was rated
on a 5-point scale, with anchors ranging from 1 = strongly
disagree to 5 = strongly agree. The α for the sample was .92.
Using a commensurate cutoff to the BDI-PC’s score of 4 (Beck
et al., 1997; Steer, Cavalieri, Leonard, & Beck, 1999), those
who endorsed a 4 or greater on at least four of the seven items
(n = 234, 36.6% of total sample) were identified as having
probable depression.

Alcohol abuse severity was assessed with the CAGE (Ew-
ing, 1984), a 4-item questionnaire that assesses the presence of
clinically significant alcohol use. Coefficient α was .80 in the
current sample. Based on commonly-used criteria for classi-
fying probable alcohol abuse (Buchsbaum, Buchanan, Centor,

Schnoll, & Lawton, 1991), those who had a minimum score of
2 (n = 100, 15.6% of total sample) were identified as having
probable alcohol abuse.

Drawing from items in the 2001 Veterans Health Study (Ka-
plan, 2004), participants were asked about use of nine categories
of mental health and substance abuse care in the past 6 months:
(a) outpatient mental health care, (b) inpatient mental health
care, (c) emergency room visit for mental health care, (d) inpa-
tient care for alcohol abuse, (e) inpatient care for drug abuse, (f)
outpatient care for alcohol abuse, (g) outpatient care for drug
abuse, (h) methadone clinic visits, and (i) medications or pre-
scriptions for mental health conditions. For the purposes of the
present research, mental health and substance abuse treatment
use was defined dichotomously (yes/no) and represented use of
any of these types of care.

A modified version of the 13-item Marlowe-Crowne Social
Desirability Scale (Crowne & Marlow, 1960; Reynolds, 1982)
was used to measure the tendency to describe oneself in a so-
cially desirable manner. Scores on this variable were computed
as the number of item responses in the keyed direction based
on a 5-point response format in which 1 = very false and 5 =
very true. The coefficient α was .79 in the current sample.

Data Analysis

To adjust for the oversampling of women, we first computed
sampling design weights that were based on population values
provided by the DMDC and set equal to the reciprocal of the
stratum sampling probability. We next computed nonresponse
bias weights by performing a logistic regression on the full
sample of potential participants with returned survey (0/1) as
the dependent variable and DMDC variables representing age,
gender, race, marital status, service component, military rank,
and branch of service as independent variables. The recipro-
cal of the resulting estimate of the probability of returning the
survey represented the nonresponse bias weight. A product of
these two weights was applied in all analyses using the STATA
10.0 software program along with recognition of gender strati-
fication in the survey design, to enhance the representativeness
of study findings to the larger population.

To document overall mental health beliefs, we calculated
weighted mean scores for each of the five scales. We also cal-
culated the weighted proportions of individuals who somewhat
or strongly agreed, somewhat or strongly disagreed, or neither
agreed nor disagreed with individual items and overall scales.
Next, we ran a series of weighted linear regressions to exam-
ine differences between individuals who did and did not meet
criteria for probable PTSD, depression, and alcohol abuse on
mental health beliefs, accounting for social desirability. A final
set of separate weighted logistic regressions examined associa-
tions between mental health belief measures and mental health
service use among individuals who met probable criteria for
these three conditions, accounting for social desirability and
symptom severity.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

310 Vogt, Fox, and Di Leone

Results

We first addressed the question of what mental health beliefs
are most commonly reported by OEF/OIF veterans. Of the
five mental health belief scales, Concerns about Stigma in the
Workplace had the highest overall average mean (M = 23.74, SE
= 0.42), followed by Negative Beliefs about Treatment Seeking
(M = 21.78, SE = 0.41), Negative Beliefs about Mental Health
Treatment (M = 20.34, SE = 0.34), Concerns about Stigma
from Loved Ones (M = 19.30, SE = 0.44), and Negative Beliefs
about Mental Illness (M = 18.56, SE = 0.34). Mean scores for
all scales were significantly different from one another (ps < .05).

Table 1 presents the results of both the scale- and item-level
examination of responses on the five mental health belief scales.
Overall, only 15.0% of participants were classified as generally
agreeing that stigma from loved ones is a concern. Slightly more
than half of the sample generally disagreed with these items,
and about a third fell in the neither agree nor disagree category.
At the item level, more than half of all participants indicated
that they disagreed with seven of the eight items. Between a
quarter and a third of participants, however, agreed that friends
and family would feel uncomfortable around them, would think
less of them, and would view them as weak if they had a mental
health problem.

Participants appeared to be more concerned about stigma in
the workplace. Overall, one third of all participants were classi-
fied as generally agreeing that stigma in the workplace is a con-
cern. An additional 41.2% fell within the neither agree nor dis-
agree category, and about one quarter generally disagreed with
these items. Item-level results revealed that more than half of
participants agreed that their career options would be limited if
others in the workplace knew they had a mental health problem
and almost half agreed that their coworkers would think they
were not capable of doing their jobs. Additional items in this
scale were endorsed by about one third of the sample, with re-
maining participants about evenly split between rejecting items
and indicating that they neither agreed nor disagreed with them.

In general, participants did not strongly endorse negative
stereotypes of mental illness. At the scale level, more than
half of participants were classified as generally disagreeing
with items on the scale. At the item level, however, more than
a quarter of participants agreed that it would be difficult to
maintain a normal relationship with someone with mental health
problems and that people with mental health problems often
use their problems as an excuse. In addition, between about a
quarter and a third of participants indicated that their beliefs on
these issues were either neutral or undecided.

Although more than one third of the sample generally dis-
agreed with items reflecting negative beliefs about mental health
treatment, 50.0% of the sample was classified in the neither
agree nor disagree category, suggesting that they may be neu-
tral or undecided in their beliefs about mental health treatment.
Item-level responses generally mirrored the scale level results,
with the one exception of beliefs about the side effects of medi-
cations. More than one third of the sample indicated that medi-

cations for mental health problems have too many negative side
effects.

Finally, for beliefs about treatment seeking, 40.0% was clas-
sified as generally disagreeing with these items and more than a
third of participants responded in a manner that suggested that
they were neutral or undecided in their beliefs. When looking at
the individual items, the majority of participants disagreed with
all but two of the items. More than half of the sample agreed
that a problem would have to be very bad before they would
seek treatment, and more than a third of the sample agreed that
they would prefer to deal with a mental health problem on their
own rather than seek mental health treatment.

We next addressed how mental health beliefs differed based
on mental health status. As indicated in Table 2, individuals
with probable diagnoses of depression and PTSD, but not al-
cohol abuse, reported being more concerned about stigma from
loved ones and in the workplace than those without these condi-
tions. There were no significant differences between those with
and without these probable mental health diagnoses on per-
sonal beliefs about mental illness and mental health treatment,
with one exception. Specifically, individuals with probable de-
pression endorsed more negative beliefs about mental health
treatment than those without this probable diagnosis.

Our final analyses examined how mental health beliefs were
associated with use of mental health and substance abuse treat-
ment. For veterans with probable PTSD, only negative beliefs
about treatment seeking was associated with lower likelihood
of seeking care, F(3, 113) = 2.92, p = .037; OR = 0.88, SE =
0.04, p = .009. For veterans with probable depression, negative
beliefs about mental illness, F(3, 219) = 7.30, p < .001; OR = 0.88, SE = 0.03, p < .001, negative beliefs about mental health treatment, F(3, 219) = 5.41, p = .001; OR = 0.90, SE = 0.04, p = .014, and negative beliefs about treatment seeking, F(3, 219) = 5.92, p < .001; OR = 0.88, SE = 0.03, p < .001 were all associated with lower likelihood of service use. For those with probable alcohol abuse, only negative beliefs about treatment seeking was associated with lower likelihood of service use, F(3, 98) = 4.21, p = .008; OR = 0.83, SE = 0.04, p = .001. No other significant results emerged.

Discussion

The current study produced a number of interesting findings
that offer a more nuanced perspective on the role of mental
health beliefs as a barrier to care for OEF/OIF veterans than has
been available in prior research. Consistent with prior research,
results revealed that OEF/OIF veterans endorse a variety of
mental health beliefs that have the potential to serve as barriers
to care. At the same time, findings revealed substantial variation
in the nature of these beliefs, with concerns about stigma in the
workplace and negative beliefs about treatment seeking most
commonly reported. Although it is encouraging that negative
beliefs about mental illness and mental health treatment were
less commonly reported than concerns about anticipated stigma
from others, it is important to note that many participants who
did not endorse negative beliefs did not explicitly reject these

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Mental Health Beliefs Among OEF/OIF Veterans 311

Table 1
Weighted Scale and Item Percentage Endorsements for Mental Health Belief Measures

Scale/item Disagree Neither Agree

Concerns about Stigma from Loved Ones 53.5 31.4 15.0
If had a MH problem and family/friends knew about it, they would . . .

think less of me 55.5 19.5 25.0
see me as weak 55.3 19.2 25.5
feel uncomfortable around me 45.2 21.8 33.0
not want to be around me 59.8 21.9 18.3
think I was faking 62.3 20.0 17.7
be afraid I might be violent or dangerous 49.3 22.5 28.2
think I couldn’t be trusted 60.1 22.8 17.1
avoid talking to me 67.4 17.3 15.3

Concerns about Stigma in the Workplace 25.5 41.2 33.3
If had a MH problem and people at work knew . . .

they would think I was incapable of doing my job 28.7 25.1 46.2
they would not want to be around me 36.4 28.1 35.5
my career/job options would be limited 23.0 21.7 55.3
they would feel uncomfortable around me 29.4 28.3 42.3
a supervisor might give me less desirable work 31.3 34.2 34.5
a supervisor might treat me unfairly 37.1 31.9 31.0
they would think I was faking 43.7 34.8 21.5
they would avoid talking to me 39.6 31.9 28.5

Negative Beliefs about Mental Illness 53.8 41.1 05.1
People with MH problems cannot be counted on. 57.4 28.3 14.3
People with MH problems use them as an excuse. 39.2 37.2 23.6
Most people with MH problems are just faking their symptoms. 68.8 26.6 04.6
I don’t feel comfortable around people with MH problems. 59.7 29.4 11.0
It is difficult to have a normal relationship with a person with MH Problems. 43.9 27.4 28.7
Most people with MH problems are violent or dangerous. 67.5 28.1 04.4
People with MH problems require too much attention. 52.7 35.4 11.9
People with MH problems can’t take care of themselves. 65.9 25.4 08.7

Negative Beliefs about MH Treatment 42.5 50.0 07.5
Medications for MH problems are ineffective. 44.4 37.6 18.0
MH treatment just makes things worse. 57.9 31.6 10.5
MH providers don’t really care about their patients. 63.5 25.5 11.0
MH treatment generally does not work. 52.6 39.0 07.4
Therapy/counseling does not really help for MH problems. 58.1 35.8 06.1
MH treatment often requires treatments people don’t want. 36.9 42.5 20.6
Meds for MH problems have too many negative side effects. 18.7 45.3 36.0
MH providers stereotype patients based on race, sex, etc. 42.7 41.0 16.3

Negative Beliefs about Treatment-Seeking 40.0 35.7 24.3
I would think less of myself if I sought MH treatment. 56.8 21.3 21.9
A problem would have to be really bad to seek MH care. 25.5 15.9 58.6
Seeing a MH provider would make me feel weak. 53.3 21.1 25.6
I would feel uneasy talking with a MH provider. 48.9 17.8 33.3
I would prefer to deal with MH problems myself. 41.9 16.9 41.2
Most MH problems can be handled without professional help. 41.3 36.5 22.2
If I sought MH treatment, I would feel stupid for not handling the problem myself. 51.6 21.6 26.8
I wouldn’t want to share personal information with a MH provider. 48.4 26.6 25.0

Note. N = 640. Percentages reported are weighted. Disagree = strongly disagree and agree; Agree = strongly agree and agree. Items are truncated. MH = mental health.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

312 Vogt, Fox, and Di Leone

Table 2
Weighted Regressions Examining Differences in Mental Health Beliefs based on Probable PTSD, Depression, and Alcohol Abuse

PTSD Depression Alcohol abuse

n = 595 n = 601 n = 600
Scale B SE t r B SE t r B SE t r

Concern about Stigma from Loved Ones 3.54 1.30 2.72* .11 3.53 0.98 3.62* .15 1.96 1.27 1.54 .06
Concern about Stigma in the Workplace 2.59 1.10 2.35* .10 2.97 0.92 3.21* .13 1.85 1.16 1.600 .07
Negative Beliefs about Mental Illness −1.68 0.89 −1.89 .08 0.61 0.71 0.85 .03 0.09 0.87 0.11 .00
Negative Beliefs about MH Treatment 1.76 0.92 1.92 .08 1.70 0.69 2.44* .10 0.74 0.84 0.89 .04
Negative Beliefs about Treatment Seeking −0.82 1.06 −0.77 .03 1.64 0.86 1.91 .08 0.44 1.04 0.42 .02
Note. All regressions included social desirability in the model. PTSD = posttraumatic stress disorder; MH = mental health.
*p < .05.

beliefs either (i.e., they indicated that they neither agreed nor
disagreed with items). To the extent that these neutral responses
suggest that individuals are ambivalent regarding their beliefs,
this group may be an ideal target for interventions aimed at cor-
recting misperceptions about mental illness and mental health
treatment. It is also possible, however, that neutral responses
may mask more negative underlying beliefs for individuals who
are sensitive to the fact that endorsing negative beliefs about
mental illness and treatment is not socially desirable. Future re-
search is needed to better understand the factors that contribute
to this more neutral response style.

Item-level analyses produced a number of results that sug-
gest promising targets for intervention. For example, although
beliefs about mental health treatment were generally positive, a
substantial portion of respondents reported concerns about the
side effects of psychotropic medications, which may serve as
a key barrier to treatment. This finding is consistent with the
broader literature suggesting that many veterans have misgiv-
ings about psychotropic medications (Zinzow, Britt, McFadden,
Burnette, & Gillispie, 2012), and underscores the importance of
providing attractive alternative treatment options. Another im-
portant direction for future research will be the investigation of
condition-specific beliefs, as veterans may be more concerned
about treatments for some disorders than others. Current find-
ings also point to the need for greater education regarding when
symptoms warrant treatment, as a majority of the OEF/OIF vet-
erans reported that they would only seek treatment if problems
were very bad. Without sufficient recognition of the benefit
of early treatment seeking, many veterans who would bene-
fit from treatment may only seek care when symptoms are so
debilitating that they are more difficult to treat.

As expected, findings revealed that individuals with probable
mental health problems, at least those with PTSD and depres-
sion, were more likely to report negative mental health beliefs
than those without these mental health problems. One expla-
nation for this finding is that stigma may become more salient
for individuals who experience mental health problems (Green-
Shortridge, Britt, & Castro, 2007), which may lead to greater
concerns about stigma from others, as well as more negative

appraisals of mental illness and mental health treatment. Lon-
gitudinal studies are needed to better understand the nature of
this relationship.

Findings also demonstrated that personal beliefs about men-
tal illness and mental health treatment, but not concerns about
stigma from others, were related to mental health and substance
abuse service use. Particularly noteworthy was the finding that
negative beliefs about treatment seeking were related to lower
likelihood of seeking care for all three mental health conditions,
with one of the highest effect sizes observed in the study. Thus,
not only are negative beliefs related to mental health treatment-
seeking common, but they also appear to serve as a potential
barrier to care for this population. In contrast, though concern
about stigma in the workplace was most commonly reported
by OEF/OIF veterans, they were not related to service use.
It remains to be seen, however, whether this potential barrier
to care would be associated with service use in a sample of
current service members, for which mental health records are
readily available to commanding officers and can be used to
make career-related decisions.

Overall, these results are consistent with our hypothesis that
an individual’s own mental health beliefs are a more important
barrier to care than concerns about stigma from others. This
finding has important implications for intervention, as it sug-
gests that efforts to target veterans’ own beliefs related to mental
health issues may be more beneficial than interventions focused
on addressing stigma from outside sources. Of course, this find-
ing requires replication in a longitudinal study before it can be
confirmed with greater certainty, as a key limitation of the cur-
rent study was the cross-sectional design. Moreover, additional
research is needed with even more representative samples, as
it is possible that even with the application of nonresponse
bias weights in this study, respondents may have differed from
nonrespondents on other unmeasured variables.

Given that the focus of the current study was limited to cor-
relates of use of any mental health care, another direction for
future research is to examine differential predictors of initiation
of treatment and treatment retention. It is also important to rec-
ognize that many factors beyond mental health beliefs are likely

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Mental Health Beliefs Among OEF/OIF Veterans 313

to influence service use, and future research should examine the
contribution of mental health beliefs relative to other potential
barriers to care. Ultimately, research that can pinpoint and ad-
dress factors that impede service use is essential to ensure that
all veterans who would benefit from treatment receive the care
they both need and deserve.

References
Beck, A. T., Steer, R. A., Ball, R., Ciervo, C. A., & Kabat, M. (1997). Use of

the Beck Anxiety and Depression Inventories for primary care with medical
outpatients. Assessment, 4, 211–219.

Brown, M. C., Creel, A. H., Engel, C. C., Herrell, R. K., & Hoge,
C. W. (2011). Factors associated with interest in receiving help for
mental health problems in combat veterans returning from deployment
to Iraq. The Journal of Nervous and Mental Disease, 199, 797–801.
doi:10.1097/NMD.0b013e31822fc9bf

Buchsbaum, D., Buchanan, R., Centor, R., Schnoll, S., & Lawton, M. (1991 ).
Screening for alcohol abuse using CAGE scores and likelihood ratios. Annals
of Internal Medicine, 115, 774–777. doi:10.7326/0003-4819-115-10-774

Corrigan, P. W. (2004). How stigma interferes with mental health care. Amer-
ican Psychologist, 59, 614–625. doi:10.1037/0003-066X.59.7.614

Corrigan, P. W., & Rüsch, N. (2002). Mental illness stereotypes and clinical
care: Do people avoid treatment because of stigma? American Journal of
Psychiatric Rehabilitation, 6, 312–334. doi:10.1080/10973430208408441

Crowne, D. P., & Marlowe, D. (1960). A new scale of social desirability inde-
pendent of psychopathology. Journal of Consulting and Clinical Psychology,
24, 349–354. doi:10.1037/h0047358

Dillman, D. A., Smyth, J. D., & Christian, L. M. (2009). Internet, mail, and
mixed-mode surveys: The tailored design method (3rd ed.). New York, NY:
Wiley.

Elbogen, E. B., Wagner, H. R., Johnson, S. C., Kinneer, P., Kang, H., Vasterling,
J. J., . . . Beckham, J. C. (2013). Are Iraq and Afghanistan veterans using
mental health services? New data from a national random-sample survey.
Psychiatric Services, 64, 134–141. doi:10.1176/appi.ps.004792011

Ewing, J. A. (1984). Detecting Alcoholism: The CAGE Question-
naire. Journal of the American Medical Association, 252, 1905–1907.
doi:10.1001/jama.1984.03350140051025

Green-Shortridge, T. M., Britt, T. W., & Castro, C. A. (2007). The stigma of
mental health problems in the military. Military Medicine, 172, 157–161.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., &
Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health
problems, and barriers to care. New England Journal of Medicine, 351,
13–22. doi:10.1056/NEJMoa040603

Kaplan, R. M. (2004). Achievements of the Veterans Health Study. Jour-
nal of Ambulatory Care Management, 27, 136–137. doi:10.1097/00004479-
200401000-00010

Kehle, S. M., Polusny, M. A., Murdoch, M., Erbes, C. R., Arbisi, P. A., Thuras,
P., & Meis, L. A. (2010). Early mental health treatment-seeking among U.S.
National Guard soldiers deployed to Iraq. Journal of Traumatic Stress, 23,
33–40. doi:10.1002/jts.20480

Kim, P. Y., Britt, T. W., Klocko, R. P., Riviere, L. A., & Adler, A.
B. (2011). Stigma, negative attitudes about treatment, and utilization
of mental health care among soldiers. Military Psychology, 23, 65–81.
doi:10.1080/08995605.2011.534415

Nash, W. P., Silva, C., & Litz, B. T. (2009). The historic origins of military and
veteran mental health stigma and the stress injury model as a means to reduce
it. Psychiatric Analysis, 39, 789–794. doi:10.3928/00485713-20090728-05

Olmsted, K. L. R., Brown, J. M., Vandermaas-Peeler, J. R., Tueller, S. J.,
Johnson, R. E., & Gibbs, D. A. (2011). Mental health and substance
abuse treatment stigma among soldiers. Military Psychology, 23, 52–64.
doi:10.1080/08995605.2011.534414

Pietrzak, R. H., Johnson, D. C., Goldstein, M. B., Malley, J. C., & South-
wick, S. M. (2009). Perceived stigma and barriers to mental health care
utilization among OEF-OIF veterans. Psychiatric Services, 60, 1118–1122.
doi:10.1176/appi.ps.60.8.1118

Reynolds, W. M. (1982). Development of reliable and valid short forms
of the Marlowe-Crowne Social Desirability Scale. Journa1 of Clinical
Psychology, 38, 119–125 doi:10.1002/1097-4679(198201)38:1<119::AID- JCLP2270380118>3.0.CO;2-I

Rosen, C. S., Greenbaum, M. A., Fitt, J. E., Laffaye, C., Norris, V.
A., & Kimerling, R. (2011). Stigma, help-seeking attitudes, and use of
psychotherapy in veterans with diagnoses of posttraumatic stress dis-
order. The Journal of Nervous and Mental Disease, 199, 879–885.
doi:10.1097/NMD.0b013e3182349ea5

Sayer, N. A., Friedemann-Sanchez, G., Spoont, M., Murdoch, M., Parker, L.
E., Chiros, C., & Rosenheck, R. (2009). A qualitative study of determi-
nants of PTSD treatment initiation in veterans. Psychiatry, 72, 238–255.
doi:10.1521/psyc.2009.72.3.238

Schell, T. L., & Marshall, G. N. (2008). Survey of individuals previously
deployed for OEF/OIF. In T. Tanielian & L. H. Jaycox (Eds.), Invisible
wounds of war: Psychological and cognitive injuries, their consequences,
and services to assist recovery (pp. 87–115). Santa Monica, CA: RAND
Center for Military Health Policy Research.

Stecker, T., Fortney, J., Hamilton, F., & Ajzen, I. (2007). An assessment of
beliefs about mental health care among veterans who served in Iraq. Psychi-
atric Services, 58, 1358–1361. doi:10.1176/appi.ps.58.10.1358

Stecker, T., Fortney, J., Hamilton, F., Sherbourne, C. D., & Ajzen, I. (2010).
Engagement in mental health treatment among veterans returning from Iraq.
Patient Preference and Adherence, 4, 45–49. doi:10.2147/PPA.S7368

Steer, R. A., Cavalieri, T. A., Leonard, D. M., & Beck, A. T. (1999). Use of the
Beck Depression Inventory for Primary Care to screen for major depression
disorders. General Hospital Psychiatry, 21, 106–111. doi:10.1016/S0163-
8343(98)00070-X

Sudom, K., Zamorski, M., & Garber, B. (2012). Stigma and barriers to mental
health care in deployed Canadian Forces personnel. Military Psychology,
24, 414–431. doi:10.1080/08995605.2012.697368

Tanielian, T., & Jaycox, L. H. (2008). Invisible wounds of war: Psychological
and cognitive injuries, their consequences, and services to assist recovery.
Santa Monica, CA: RAND Corporation.

Vogt, D. (2011). Mental health-related beliefs as a barrier to service use for
military personnel and Veterans: Findings and recommendations for future
research. Psychiatric Services, 62, 135–142. doi:10.1176/appi.ps.62.2.135

Vogt, D., Di Leone, B. A. L., Wang, J., Sayer, N. A., Pineles, S. L., &
Litz, B. T. (2014).Endorsed and Anticipated Stigma Inventory (EASI): A
tool for assessing beliefs about mental illness and mental health treatment
among military personnel and veterans. Psychological Services, 11, 105–
113. doi:10.1037/a0032780

Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. M. (1993, Octo-
ber). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility.
Paper presented at the Annual Convention of the International Society for
Traumatic Stress Studies, San Antonio, TX.

Zinzow, H. M., Britt, T. W., McFadden, A. C., Burnette, C. M., &
Gillispie, S. (2012). Connecting active duty and returning veterans to
mental health treatment: Interventions and treatment adaptations that
may reduce barriers to care. Clinical Psychology Review, 32, 741–753.
doi:10.1016/j.cpr.2012.09.002

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.