Systematic Review of the Military Career Impact of Mental Health Evaluation and Treatment

Abstract

Introduction: Military leaders are concerned that active duty members’ fear of career impact deters mental health (MH) treatment-seeking. To coalesce research on the actual and perceived consequences of MH treatment on service members’ careers, this systematic review of literature on the U.S. Military since 2000 has been investigating the following three research questions: (1) is the manner in which U.S. active duty military members seek MH treatment associated with career-affecting recommendations from providers? (2) Does MH treatment-seeking in U.S. active duty military members impact military careers, compared with not seeking treatment? (3) Do U.S. active duty military members perceive that seeking MH treatment is associated with negative career impacts? Materials and Methods: A search of academic databases for keywords “military ‘career impact’ ‘mental health”’ resulted in 653 studies, and an additional 51 additional studies were identified through other sources; 61 full-text articles were assessed for eligibility. A supplemental search in Medline, PsycInfo, and Google Scholar replacing “career impact” with “stigma” was also conducted; 54 articles (comprising 61 studies) met the inclusion criteria. Results: As stipulated by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies were summarized on the population studied (U.S. Military Service[s]), sample used, intervention type, comparison group employed, outcome variables, and findings. Self-referred, compared with command-directed, service members appear to be less likely to face career-affecting provider recommendations in non-deployed and deployed settings although the data for the latter are not consistent. Of the two studies that tested if MH treatment actually negatively impacts military careers, results showed that those who sought treatment were more likely to be discharged although the casual nature of this relationship cannot be inferred from their design. Last, over one-third of all non-deployed service members, and over half of those who screened positive for psychiatric problems, believe that seeking MH treatments will harm their careers. Conclusions: Despite considerable efforts to destigmatize MH treatment-seeking, a substantial proportion of service members believe that seeking help will negatively impact their careers. On one hand, these perceptions are somewhat backed by reality, as seeking MH treatment is associated with a higher likelihood of being involuntarily discharged. On the other hand, correlational designs cannot establish causality. Variables that increase both treatment-seeking and discharge could include (1) adverse childhood experiences; (2) elevated psychological problems (including both [a] the often-screened depression, anxiety, and posttraumatic stress problems and [b] problems that can interfere with military service: personality disorders, psychotic disorders, and bipolar disorder, among others); (3) a history of aggressive or behavioral problems; and (4) alcohol use and abuse. In addition, most referrals are self-directed and do not result in any career-affecting provider recommendations. In conclusion, the essential question of this research area—“Does seeking MH treatment, compared with not seeking treatment, cause career harm?”—has not been addressed scientifically. At a minimum, longitudinal studies before treatment initiation are required, with multiple data collection waves comprising symptom measurement, treatment, and other services obtained, and a content-valid measure of career impact.