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Veteran help-seeking behaviour for mental health issues: a systematic review
  1. Rebecca Randles and
  2. A Finnegan
  1. Westminster Centre for Research in Veterans, University of Chester Faculty of Health and Social Care, Chester, UK
  1. Correspondence to A Finnegan, University of Chester, Chester, UK; a.finnegan{at}


Introduction Serving military personnel and veterans have been identified to have a high prevalence of mental health disorders. Despite this, only a significantly small number seek mental healthcare. With the UK beginning to invest further support to the armed forces community, identification of barriers and facilitators of help-seeking behaviour is needed.

Methods Corresponding literature search was conducted in PsycINFO, PsycArticles, Medline, Web of Science and EBSCO. Articles which discussed barriers and facilitators of seeking help for mental health concerns in the veteran population were included. Those which discussed serving personnel or physical problems were not included within this review. A total of 26 papers were analysed.

Results A number of barriers and facilitators of help-seeking for a mental health issue within the veteran population were identified. Barriers included stigma, military culture of stoicism and self-reliance, as well as deployment characteristics of combat exposure and different warzone deployments. Health service difficulties such as access and lack of understanding by civilian staff were also identified. Facilitators to help combat these barriers included a campaign to dispel the stigma, including involvement of veterans and training of military personnel, as well as more accessibility and understanding from healthcare staff.

Conclusions While some barriers and facilitators have been identified, much of this research has been conducted within the USA and on male veterans and lacks longitudinal evidence. Further research is needed within the context of other nations and female veterans and to further indicate the facilitators of help-seeking among veterans.

  • mental health
  • adult psychiatry
  • public health

Data availability statement

No data was utilised in this systematic review, therefore no data is available. Articles are freely available in the databases listed within the systematic review. All articles used for collection are within the reference list and available for distribution.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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Key messages

  • Serving military personnel and veterans have a high prevalence of mental disorders, but only a significantly small number seek help.

  • Barriers to help-seeking behaviour included stigma, military culture of stoicism and self-reliance as well as deployment characteristics such as combat exposure.

  • Facilitators of help-seeking included dispelling the stigma and myths surrounding help-seeking and mental health treatment as well as involvement of other veterans.

  • Further research is needed within the UK context with the lack of longitudinal evidence on the barriers and facilitators as well as the limited research on female veterans.


Serving military personnel and veterans have been identified to have a high prevalence of mental health (MH) disorders.1 2 Despite this, only a significantly small number seek MH care.3 4 With the UK beginning to invest further support to the armed forces community (AFC), identification of barriers and facilitators of help-seeking behaviour is needed.5–7 Help-seeking behaviour is defined as a planned behaviour of actively seeking help with a healthcare professional due to changes in health.8 Facilitators and barriers to help-seeking behaviour in reference to MH difficulties have been frequently researched in the literature.9–12 Certain MH disorders within the veteran community have been found to be associated with more substantial health service utilisation, with collaboration between primary healthcare and MH services attributing to successful support and treatment for veterans.13

Primary healthcare within the UK is expected to record and support their veterans through prioritisation and veteran-specific services.5 6 14 Research has shown as little as 8.7% of veterans have been identified, with many healthcare staff and veterans not seeing the benefit in recording a veteran’s status, leading to barriers among veterans who are seeking support.15 More recently, the UK NHS has introduced Op COURAGE, which aims to support the AFC by providing bespoke MH and well-being services.5–7 There is UK research regarding help-seeking behaviour in the armed forces12 and the use of social prescribing activities such as archaeology16 to help facilitate access to appropriate support. However, the focus of this article is the identification of barriers and facilitators of help-seeking behaviour and the beneficial approaches to understand how the military veteran community can be better supported.


Literature search strategy

A rapid review of the literature was conducted over a period of three months. This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).17 Corresponding literature searches wereconducted in the following databases: PsycINFO, PsycArticles, Medline, Web of Science and EBSCO. These databases were selected due to the quality of their peer-reviewed publications and their utilisation in previous literature review publications of a similar focus. Furthermore, the journal impact factors of the BMJ Military Health and Military Medicine were searched due to their focus and credibility in armed forces research. Databases were limited to those written in the English language and published in peer-reviewed/academic journals, with years 1990–2021 as inclusion criteria. Only two articles were included before the year 2000 with the rationale of providing deployment contexts to help-seeking behaviour.

Inclusion and exclusion criteria

Articles that discussed veteran help-seeking behaviour towards MH services were included, specifically those that discussed barriers and/or facilitators of help-seeking behaviour. A methodological consideration should be noted that treatment-seeking is often used interchangeably with help-seeking. Therefore should a publication fall in line with the meaning of help-seeking behaviour, this was also included despite using an alternative term. Publications which discussed serving personnel were not included in the review, even if this was in conjunction with the discussion of veterans. This is due to the focus of the review being the help-seeking behaviour of veterans. The authors acknowledge that MH disorders often originate from physical health problems; however, the focus of this review was primarily help-seeking for MH disorders and physical problems were excluded. The selection of the papers was conducted by the first author and this is therefore a single-screening review. Although there is potential for selection bias in a single-screening approach, due to the rapid nature of the review and the systematic approach of selection using the PRISMA guidelines, this single-screening approach is more accepted.18 19 The second author was available to discuss the selections and confirm those for inclusion. Table 1 details the search of the literature review.

Table 1

Search parameters of the literature review


The search consisted of the following stages:

  • Initial search: search of keywords as defined in Table 1.

  • Duplicate removal: duplicates across databases and journals were removed.

  • Title/abstract screening: title and abstract were screened to look for relevance.

  • Paper screening: full publications were then screened to check that there was discussion surrounding the barriers and/or facilitators of veteran help-seeking behaviour for MH problems. Figure 1 outlines these stages in more detail.

Figure 1

PRISMA flow diagram of literature review publication selection. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.


Numerous studies demonstrated that veterans were able to recognise that they had current MH issues, with as many as 76.6% reporting problems.20 In the USA, research has revealed 72% of veterans screening positive for a MH disorder, suggesting that veterans are accurately able to recognise a MH problem.21 In contrast, there is evidence that veterans were generally poor at identifying symptoms of mental distress.22 Despite this recognition and prevalence of mental disorders, small numbers of veterans reported accessing MH services.23–25 However, there were several factors that increased the likelihood of accessing MH services, such as symptom severity, support networks and being in crisis.26–28

Barriers to help-seeking behaviour

Barriers to help-seeking behaviour were highly homogenous across the literature, with similar themes appearing despite research coming from several different countries. However, there was a transatlantic dialogue from the USA that did not translate to other countries, and that is a barrier of affordability of healthcare.29–32 This was of particular concern to the homeless veteran population, despite their lack of income entitling them to free healthcare.33 Within some countries, these concerns were not present due to the free healthcare that is available to the entire population. However, the NHS was seen as having long waiting lists and difficulties of access.22 Furthermore, a veteran study in Denmark stated that there was a lack of veteran-specific services.24 Therefore, there are barriers to veterans’ help-seeking behaviour which are nation-specific.


Several types of stigma were described among the literature as barriers to help-seeking: internalised stigma, anticipated stigma and public stigma.23 27 34 35 Internalised stigma refers to veterans’ negative beliefs regarding MH problems and treatment-seeking, such as feeling ashamed.34 36 Furthermore, there was also an internalised belief that seeking treatment would make veterans appear ‘weak’.31 In addition, there were several negative stigmatising beliefs held by veterans in regard to MH, such as believing those with MH problems cannot be counted on or take care of themselves.28 Internalised stigma suggests that veterans’ own negative beliefs regarding MH are a barrier to help-seeking behaviour, as having these beliefs would impede on wanting to seek help for MH problems due to fear.22 29 34 36 However, internalised stigma has, on occasions, been found to not be significantly associated with poor help-seeking.28 37 This lack of significant effect could be due to a veteran’s perceived need for care, mediating the relationship between internalised stigma and help-seeking.35

Anticipated stigma refers to stigma that veterans would expect to receive from others.34 38 As many as 29.9% of veterans believed that, if they had a MH problem, their friends and family would feel uncomfortable around them.28 Further literature reported that veterans’ lack of help-seeking was due to fear of a MH problem interfering with their career and career prospects.22 25 This would suggest that anticipated stigma from others may hinder veterans from wanting to seek help for an MH condition due to fear of how others would perceive them.

Public stigma refers to a belief that the general population would perceive them as ‘damaged goods’.25 29 33 39 Veterans were often concerned with the stigmatising labels that are associated with MH issues, such as being viewed as ‘crazy’, with as many as 44% of veterans agreeing that accessing treatment would make them appear weak.21 32 Despite this, only 12% of veterans agreed that they themselves would view others as weak if they sought treatment.21 Public stigma was particularly prominent in veterans within the homeless population who believed that, due to their homeless status, they would be more likely to be treated poorly, which hindered their motivation to receive help for any MH concerns.33 In addition, veterans also felt that they were stigmatised by the general public due to any MH problem that has been induced by their service, as they believed that some civilians view their service as an ‘adventurous vacation’, with some even viewing them as murderers.38

However, Cerully et al 37 found a lack of longitudinal data for assessing the relationship between MH stigma, particularly within the veteran population. Data consisted of a small number of studies which found no relationship between self-stigma and treatment-seeking. However, self-stigma was found to be positively related to treatment attrition. This suggests that much of the literature we currently have regarding stigma and help-seeking behaviour in the veteran population employed a cross-sectional and self-reported method of data collection, which holds the limitations of being less objective and makes it difficult to make causal inferences. Furthermore, there is lack of research regarding stigma among female veterans, although it has been found that female veterans have significantly lower levels of internalised stigma than male veterans.40

Military culture, identity and characteristics

Military culture and identity prescribes to the idea that soldiers should be heavily self-reliant, with a frequently cited emphasis on stoicism.27 29 31 41 This identity means that veterans often cite the military culture of prioritising fulfilment of a mission over personal discomfort as well as of sickness being regarded as a sign of weakness.22 32 39 41 42 This sense of pride that veterans hold and their belief that admitting they need MH support would mean they were no longer a ‘hero’ suggest that veterans do not seek help due to a sense of honour.25 38

Female veterans are often overlooked in the literature, potentially due to them being a smaller population within the military. However, studies have indicated that female veterans report higher pressure to uphold the reputation of female service members, citing that women are often not taken seriously within the military.40 43 Many female veterans have adopted the same attitudes as male veterans in not wanting to appear weak.40 43 Subsequently, female veterans feel the need to ‘prove’ their strength with a sense of competitiveness towards their male counterparts, with one female veteran suggesting that men are in fact better at encouraging help-seeking than women within the military.29 43 However, from a quantifiable data point, no gender differences were found, suggesting that help-seeking behaviours across both genders in military veterans were the same,31 43 although there has been some research which suggests men have more negative beliefs towards MH than women.28 However, these gender differences within the veteran population are significantly under-researched.

Help-seeking behaviour may also be attributed to history of operational deployments and unit characteristics particularly when it comes to combat exposure.26 It has been found that every increase of 1 SD when measuring veterans’ combat exposure increased their likelihood of using a veteran service by 81%.26 This can be supported by a US study by Krill Williston et al,28 who found that veterans who served on active duty reported more negative beliefs about treatment-seeking than those who were in the national guard or reserves. In addition, when comparing veterans who deployed to different warzones, veterans who were deployed to Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) were significantly more likely to dislike talking in groups, feel that treatment makes them appear weak and that previous attempts at treatment did not help compared with veterans from the Vietnam War.31 This may also be due to combat exposure or the experiences on those particular deployments. Furthermore, painful self-conscious emotions, such as guilt and shame, were found to be significantly associated with emotional control and self-reliance for veterans who had been deployed to a warzone, suggesting that those who had higher combat exposure may be more likely to attempt to self-treat any MH problems, likely due to military attitudes of self-reliance.27 44 Further Vietnam veteran research indicated that veterans who did not want to be in the military or deploy did not seek help for any veteran-related issues.45 Therefore, this may also be the case for those who were recruited for national service in the UK or any other form of military conscription. In addition, veterans from the OEF/OIF deployment had much greater perceptions that they would not fit into the US Department of Veterans Affairs, further highlighting that deployment and unit characteristics have an effect on help-seeking behaviour.46

Access to health services

Help-seeking behaviour appeared to be hindered by difficulties in access and usage of MH services. Accessibility was quite a prominent problem, with veterans discussing issues such as transportation, lack of appointments available as well as staffing issues.30 32 Veterans reported a dissatisfaction with their encouragement to seek help on leaving the military as well as with the services that were available, specifically for veterans.32 36 42 This lack of US veteran-specific services led to veterans believing that the civilian healthcare providers would not understand what they were going through and that it would be difficult to discuss such problems with a stranger.22 30 36 This meant that veterans prioritised ‘basic needs’ over seeking MH treatment, such as housing and employment.29 Further concerns regarding accessibility can be found within the veteran homeless population, such as having no form of identification or a place where they can be regularly contacted.33

There were also concerns regarding privacy and security.27 30 32 36 Some veterans reported distrust of the healthcare system and fearing what may be done with confidential information.30 32 36 In addition, veterans reported that services were non-responsive and ineffective and have limited resources to be able to deal with problems outside of business hours.27 30 The reasons for holding this belief may be due to previous experiences with the healthcare system, where some veterans have reported being discharged when they were still in need of help.22 42

Facilitators of help-seeking behaviour

Barriers to help-seeking behaviour were more heavily researched than that of the facilitators. However, the facilitators that were found were highly homogenous across the literature. Veterans believed that dispelling the stigma that currently exists surrounding MH would help to facilitate help-seeking behaviour.36 Recommendations included an awareness campaign that would normalise the help-seeking process through the use of personal stories from other veterans as well as improving veteran awareness of available services.22 36 Enhanced awareness as a facilitator is supported by Williston et al,35 who reported that veterans with higher MH literacy endorsed less negative beliefs about help-seeking and that there was no relationship between literacy and actual utilisation of MH services.

Moreover, recommendations were made surrounding training those in leadership positions within the military.36 Some veterans believed that making MH educational sessions mandatory would help to facilitate help-seeking behaviour, while others felt that this would lead to a lack of engagement.36 Many agreed that the involvement of a veteran as a mentor would further facilitate help-seeking,36 and veterans perceived that seeing another veteran seek help for their own MH concerns was a crucial facilitator in dispelling the stigma and would often lead to them seeking help.22

Health service facilitators and symptom severity

Veterans who were able to recognise that they had a problem were more than seven and a half times more likely to be interested in receiving help.20 This suggests that recognition of a problem is a facilitator of help-seeking behaviour.30 47 In addition, the severity of the symptoms that a veteran is experiencing can also facilitate help-seeking behaviour, with veterans often commenting that the problem would have to be ‘severe’ for them to seek treatment.22 Research indicated that depression severity is significantly positively correlated with MH treatment usage, meaning that those with more severe depression were more likely to seek treatment.24 26 34 45 This symptom severity was also associated with a veteran’s perceived need for care, where encouragement from a veterans’ support network can increase the potential of a veteran to seek help.27 39 Furthermore, veterans’ perceived need for care was usually due to no longer being able to self-manage the symptoms that they were experiencing.22 42 This would suggest that veterans experiencing severe symptoms regarding their MH would motivate them to seek support for their MH concerns as they would also be more likely to recognise that there was a problem, particularly if they felt they were no longer able to self-manage their symptoms.

The accessibility of MH services was discussed as a potential facilitator of help-seeking.27 30 32 36 Veterans revealed that MH treatment would be more easily accessible if the first point of contact could be a telephone call or via online communication, as well as being more accessible outside of working hours, where veterans were likely to need additional support.27 36 This accessibility was also facilitated when veterans held beliefs that were more treatment-encouraging, such as believing getting help was socially acceptable, that the opinions of other people did not matter, that treatment is helpful and that those who are encouraging help-seeking are trustworthy.30 42 In addition, veterans’ views on how the MH services could be better conducted to facilitate help-seeking appeared to differ drastically, with some emphasising the need for inperson contact and others believing online services would be more ideal to combat the barrier of fearing their confidential information would be shared as this format would allow for anonymity.32 36 Furthermore, Vietnam veterans reported wanting a more professional environment for when they receive treatment, with other veterans stating that they did not feel comfortable discussing their MH in a hospital-like environment.42 The facilitators and barriers to help-seeking are provided diagrammatically in Figure 2.

Figure 2

Identified barriers and facilitators of veterans’ help-seeking behaviour.


While research is available on veteran help-seeking behaviour, currently this remains heavily focused on the USA, with female veterans and longitudinal data also being under-researched. However, barriers and facilitators of help-seeking behaviour can still be identified and potentially used to better support veterans in a UK context. Barriers identified were that of stigma, military culture of stoicism, unit characteristics such as warzone deployment, as well as service difficulties such as access and understanding. Facilitators were found to be suppressing the stigma through awareness campaigns and using military leaders and other veterans to promote help-seeking as well as those in crisis being more likely to seek help. Identifying the reasons for poor help-seeking behaviour and where veterans have sought support is part of the evaluation of the Armed Forces Covenant Fund Trust’s Serious Stress programme,48 with results due later in 2021. However, further research is needed to better understand how the AFC can be better supported to seek help for MH-related problems.

Data availability statement

No data was utilised in this systematic review, therefore no data is available. Articles are freely available in the databases listed within the systematic review. All articles used for collection are within the reference list and available for distribution.

Ethics statements

Patient consent for publication



  • Twitter @becky_randles

  • Contributors RR: primary author, led on the systematic review, interpretation of results and author of the first draft. AF: review and critique of drafts, approval of final submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The views are solely those of the authors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.