Do stigma and efficacy mediate the association between training and suicide prevention behavior among Army noncommissioned officers?

INTRODUCTION: Rates of suicide in the Active Component of the military have significantly increased since 2010, with particularly high rates among Army service members. One element of the Army's approach to suicide prevention relies on noncommissioned officers (NCOs) as gatekeepers who have regular contact with soldiers. NCOs receive suicide prevention training, but there is limited evidence that such training leads to behavior change. METHODS: We surveyed 2468 Army NCOs participating in leadership development courses to determine (a) if training on suicide prevention and soft skills (e.g., active listening) was associated with gatekeeper behavior and use of soft skills; and (b) whether that association was explained by two potential barriers, stigma and perceptions of efficacy. RESULTS: Both the number of suicide prevention training topics and soft skills trained were associated with increased gatekeeper behavior; these relationships were explained in part by lower stigma and higher efficacy for use of soft skills. The use of interactive training methods and receiving coaching after training were not associated with stigma or efficacy, though both methods were associated with more frequent use of soft skills. CONCLUSION: Results suggest that the content and format of training is important to preparing NCOs to fulfill a gatekeeper role.

Upstream suicide prevention in the U.S. Army: Noncommissioned officers' perspectives.

The goal of this study was to examine the factors associated with Army noncommissioned officer (NCO) experiences, attitudes, and behaviors in their role of identifying potential suicide risk factors in their fellow soldiers. To better understand the perspectives of NCOs, an anonymous survey was administered to 2,468 Army NCOs. Descriptive statistics and linear regressions were conducted to compare subgroups of NCOs. Most (71%) Army NCOs have received many (11 or more) hours of suicide prevention training, but training in soft skills that may be important for the gatekeeper role was less consistently reported. Active Component soldiers reported greater confidence in their intervention skills (Cohen's d = 0.25) and fewer logistical barriers (e.g., time and space to talk) to intervening with at-risk soldiers (Cohen's d = 0.80) compared to Reserve and National Guard soldiers. Formal coursework in mental health areas like psychology or chaplaincy was associated with a greater level of confidence in intervention skills (Cohen's d = 0.23) and in more frequent intervention behavior (Cohen's d = 0.13). Army NCO trainings should be modified to better equip soldiers with the soft skills (e.g., active listening skills and verbally and nonverbally conveying nonjudgment/acceptance and empathy) needed to have effective conversations with soldiers about suicide risk factors and other sensitive topics. Strategies used within mental health education, which appears to be a strength for NCO gatekeepers, could be used to achieve this goal. Reserve and Guard NCOs may need additional supports and tailored trainings to better fit their operational context. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Gender Differences in Health Among U.S. Service Members: Unwanted Gender-Based Experiences as an Explanatory Factor.

Women serving in the U.S. military are more likely to report mental health problems than men, including symptoms of depression and posttraumatic stress disorder (PTSD). Women also experience much higher rates of sexual harassment, gender discrimination, and sexual assault than men. This study examines how unwanted gender-based experiences among military service members relate to differences in health. The authors find that, once experiences of gender discrimination, sexual harassment, and sexual assault are accounted for, gender differences in health are largely attenuated. That is, the vulnerability to physical and mental health problems among female service members appears to be highly correlated with these unwanted gender-based experiences. The results highlight the possible health benefits of improved prevention of gender discrimination, sexual harassment, and sexual assault, and they indicate the need to address the mental and physical health of service members exposed to these types of experiences.

Comparing the Army's Suicide Rate to the General U.S. Population: Identifying Suitable Characteristics, Data Sources, and Analytic Approaches.

Over the past 15 years, the suicide rate among members of the U.S. armed forces has doubled, with the greatest increase observed among soldiers in the Army. This increasing rate is paralleled by a smaller increase in the general U.S. population, observed across both genders, in virtually every age group and in nearly every state. An empirical question exists: What is the extent or degree to which the suicide trend in the Army is unique to that service, relative to what is observed in the general U.S. population? The Army has typically attempted to address this question by standardizing the general population to look like the Army on demographic characteristics. However, given the rise in suicide rates over the past decade, the Army wanted to better understand whether standardization based solely on age and gender is enough. Expanding the characteristics on which the general population is standardized to match the Army could be useful to gain a better understanding of the suicide trends in the Army. However, such a change also brings with it some challenges, including the lack of readily available data in the general U.S. population. In addition, even an expanded set of characteristics still results in having a large number of unmeasured factors that cannot be included in this type of analysis. In this study, the authors explore how accounting for age, gender, race/ethnicity, time, marital status, and educational attainment affects suicide rate differences between soldiers and a comparable subset of the general U.S. population.

Integrating Department of Defense and Department of Veterans Affairs Purchased Care: Preliminary Feasibility Assessment.

The U.S. Department of Defense (DoD) and U.S. Department of Veterans Affairs (VA) health systems provide services through a mix of direct care, delivered at government facilities, and purchased care, provided through the private sector, mainly by community-based providers who have entered into contracts with third-party administrators (TPAs). In the interest of expanding DoD-VA resource sharing that may lead to greater efficiencies and cost savings, the DoD/VA Joint Executive Committee is exploring options to integrate DoD and VA's purchased care programs. This preliminary feasibility assessment examined how an integrated approach to purchasing care could affect access, quality, and costs for beneficiaries, DoD, and VA and identified general legislative, policy, and contractual challenges to implementing an integrated purchased care program. An integrated approach to purchasing care is feasible under current legal and regulatory authorities, but policy changes may be needed-and the practicality of such an approach depends on the contract and network design. For example, legal/regulatory changes in how contracts are established would be required to achieve any real savings to the government. There are also differences in the populations served by TRICARE (DoD health care) and VA, particularly in terms of age and geographic location. Implementation would be further complicated by contractual differences in the TPA contracts for VA and DoD as they relate to network standards, provider payments, network participation requirements, and reporting requirements and incentive structures. As a result, there are significant uncertainties with respect to increased efficiency or cost savings for the government.

Youth victimization profiles and change in mental health symptoms over one year.

OBJECTIVE: To understand how youth PTSD symptoms and externalizing problems emerge and change over time for youth with different profiles of victimization, including polyvictimization. METHOD: We conducted a latent class analysis (LCA) to identify empirically derived victimization profiles in a sample of 2,776 youth who participated in an evaluation study. We then conducted growth curve analyses to determine whether these victimization profiles predicted change in the course of PTSD symptoms and externalizing problems over a 1-year time period for youth engaged in a variety of community-based services. RESULTS: The LCA revealed three profiles: a low victimization profile defined by relatively low endorsement of victimization across types; a witnessing profile defined by particularly high endorsement of witnessing violence; and a polyvictimization profile defined by high endorsement of multiple types of victimization. We found that overall, despite differing initial levels of PTSD symptoms and externalizing problems, all three groups' symptoms improved over the year, but the polyvictimization class generally showed the steepest decreases, particularly in caregiver-reported PTSD symptoms. CONCLUSION: Polyvictimized youth participating in community-based services are at increased risk for developing PTSD and externalizing problems, but symptoms appear to decrease to levels similar to other victimized youth after one year. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

PTSD symptoms are differentially associated with general distress and physiological arousal: Implications for the conceptualization and measurement of PTSD.

BACKGROUND: The primary purpose of this study was to examine the place of posttraumatic stress disorder (PTSD) vis-à-vis the external dimensions of general distress and physiological arousal. METHODS: Using data collected from veterans of the wars in Iraq and Afghanistan (N = 1350), latent variable covariance structure modeling was employed to compare correlations of PTSD symptom clusters and individual PTSD symptoms with general distress and physiological arousal. RESULTS: Each PTSD symptom cluster, and 17 of 20 individual PTSD symptoms were more strongly associated with general distress than with physiological arousal. However, moderate to strong associations were also found between physiological arousal and both PTSD clusters and symptoms. LIMITATIONS: Findings are based on self-reported data elicited from a single sample of veterans with substantial PTSD symptoms. Replication, particularly by clinician interview, is necessary. Generalizability to other traumatized populations is unknown. CONCLUSIONS: Results offer support, with caveats, for viewing PTSD as a distress disorder. Findings are not consistent with the position that PTSD is a hybrid disorder with some features reflecting hyperarousal and others indicative of general distress. Results have implications for the conceptualization and measurement of PTSD.

Development and preliminary evaluation of a self-guided, internet-based tool for coping with stress and trauma: Life Improvement for Teens (LIFT).

Implementation issues often interfere with delivery of evidence-based interventions for students exposed to trauma. To improve uptake of evidence-based techniques for such students, a partnership of interventionist scientists, research and development experts, and students created a self-paced, confidential, online curriculum. This article describes the program and results of an open trial in 5 schools that serve primarily ethnic minority youth in urban settings. Fifty-one middle and high school students completed surveys before and after the program, as well as within the program, to assess emotional and behavioral symptoms (depressive, anxiety, posttraumatic stress disorder [PTSD] symptoms and behavior) and purported mechanisms of action (coping, cognitions, emotional self-efficacy). Results indicated the program was feasible and acceptable, with moderate satisfaction. Despite low power in this study, we observed changes in several hypothesized mechanisms of action. In addition, we observed promising improvements in PTSD symptoms, emotional problems, and total behavioral difficulties. These findings offer the promise of using a self-help web-based tool to augment and enhance usual school support services. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Collaborative Care for Depression and Posttraumatic Stress Disorder: Evaluation of Collaborative Care Fidelity on Symptom Trajectories and Outcomes.

BACKGROUND: Despite the growing consensus that collaborative care is effective, limited research has focused on the importance of collaborative care fidelity as it relates to mental health clinical outcomes. OBJECTIVE: To assess the relationship of collaborative care fidelity on symptom trajectories and clinical outcomes among military service members enrolled in a multi-site randomized controlled trial for the treatment of depression and posttraumatic stress disorder (PTSD). DESIGN: Study data for our analyses came from a two-parallel arm randomized trial that evaluated the effectiveness of a centralized collaborative care model compared to the existing collaborative care model for the treatment of PTSD and depression. All patients were included in the analyses to evaluate how longitudinal trajectories of PTSD and depression scores differed across various collaborative care fidelity groupings. PARTICIPANTS: A total of 666 US Military Service members screening positive for probable PTSD or depression through primary care. MAIN MEASURES: Disease registry data from a web-based clinical management support tool was used to measure collaborative care fidelity for patients enrolled in the trial. Participant depression and PTSD symptoms were collected independently from research survey assessments at four time points across the 1-year trial period. Treatment utilization records were acquired from the Military Health System administrative records to determine mental health service use. KEY RESULTS: Consistent and late fidelity to the collaborative care model predicted an improving symptom trajectory over the course of treatment. This effect was more pronounced for patients with depression than for patients with PTSD. CONCLUSIONS: Long-term fidelity to key collaborative care elements throughout care episodes may improve depression outcomes, particularly for patients with elevated symptoms. More controlled research is needed to further understand the influence of collaborative care fidelity on clinical outcomes. TRIAL REGISTRATION: Clinicaltrials.gov Identifier NCT01492348.

Cost-effectiveness of collaborative care for depression and PTSD in military personnel.

OBJECTIVES: Collaborative care is an effective approach for treating posttraumatic stress disorder (PTSD) and depression within the US Military Health System (MHS), but its cost-effectiveness remains unstudied. Our objective was to evaluate the costs and cost-effectiveness of centrally assisted collaborative telecare (CACT) versus optimized usual care (OUC) for PTSD and depression in the MHS. STUDY DESIGN: A randomized trial compared CACT with OUC. Routine primary care screening identified active-duty service members with PTSD or depression. Eligible participants (N = 666) were randomized to CACT or OUC and assessed at 3, 6, and 12 months. OUC patients could receive care management and increased behavioral health support. CACT patients could receive these services plus stepped psychosocial treatment and routine centralized team monitoring. METHODS: Quality-adjusted life-years (QALYs) were derived from the 12-Item Short Form Health Survey. Claims and case management data were used to estimate costs. Cost-effectiveness analyses were conducted from a societal perspective. RESULTS: Data from 629 patients (320 CACT and 309 OUC) with sufficient follow-up were analyzed. CACT patients gained 0.02 QALYs (95% CI, -0.001 to 0.03) relative to OUC patients. Twelve-month costs, including productivity, were $987 (95% CI, -$3056 to $5030) higher for CACT versus OUC. CACT was estimated to cost $49,346 per QALY gained compared with OUC over 12 months. There is a 58% probability that CACT is cost-effective at a $100,000/QALY threshold. CONCLUSIONS: Despite its higher costs, CACT appears to be a cost-effective strategy relative to OUC for managing PTSD and depression in the MHS.

Improving Outcomes for Children Exposed to Violence: Safe Start Promising Approaches.

Children's exposure to violence is common and can lead to mental health problems and delinquent behaviors. Because many interventions have focused on specific violence types or symptoms and been difficult to implement in real-world settings, the evidence base is still emerging. The Office of Juvenile Justice and Delinquency Prevention's Safe Start Promising Approaches (SSPA) initiative focused on preventing and reducing the impact of children's exposure to violence through interventions in ten diverse communities. The evaluation examined the effectiveness of the SSPA interventions to address issues for children and families exposed to violence. The ten sites were diverse in their intervention approaches, types of violence exposure targeted, and implementation settings. To evaluate each approach's effectiveness in reducing violence's harmful effects, RAND researchers partnered with the community-based sites to develop a rigorous controlled evaluation design for each intervention, with either a randomized control group or a comparison group selected on similar characteristics. The longitudinal analyses found that families in both the intervention and comparison groups had positive gains on many outcomes, but there was no evidence that the intervention groups improved more. Among those who received Safe Start services, one site produced large, significant improvements in posttraumatic stress disorder symptoms, and another site produced medium, significant effects on several outcomes (child self-control, posttraumatic stress disorder, and behavior; caregiver depression; and family conflict). Although the initiative added to knowledge about how to address the problem, there was no clear case for using a particular intervention to help these children and their families.

The Deployment Life Study: Longitudinal Analysis of Military Families Across the Deployment Cycle.

In 2009, RAND launched the Deployment Life Study, a longitudinal study of military families across a deployment cycle in order to assess family readiness. Family readiness refers to the state of being prepared to effectively navigate the challenges of daily living experienced in the unique context of military service. The study surveyed families at frequent intervals throughout a complete deployment cycle---before a service member deploys (sometimes months before), during the actual deployment, and after the service member returns (possibly a year or more after she or he redeployed). It assessed a number of outcomes over time, including: the quality of marital and parental relationshipsthe psychological, behavioral, and physical health of family memberschild and teen well-being (e.g., emotional, behavioral, social, and academic)military integration (e.g., attitudes toward military service, retention intentions).This culminating paper briefly reviews the study design and data collection procedures, presents results from analyses of the longitudinal data collected from some 2,700 military families, and offers recommendations for programs and future research related to military families. The research was jointly sponsored by the Office of the Surgeon General, U.S. Army, and by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.

Suicide Prevention Hotlines in California: Diversity in Services, Structure, and Organization and the Potential Challenges Ahead.

This article evaluates the landscape in which suicide prevention hotlines operate, focusing on California but with nationwide implications, and provides recommendations to ensure that callers at risk of suicide seek and receive the help they need.

Stakeholder Experiences in a Stepped Collaborative Care Study Within U.S. Army Clinics.

OBJECTIVE: This article examines stakeholder experiences with integrating treatment for posttraumatic stress disorder (PTSD) and depression within primary care clinics in the U.S. Army, the use-of-care facilitation to improve treatment, and the specific therapeutic tools used within the Stepped Treatment Enhanced PTSD Services Using Primary Care study. METHODS: We conducted a series of qualitative interviews with health care providers, care facilitators, and patients within the context of a large randomized controlled trial being conducted across 18 Army primary care clinics at 6 military installations. RESULTS: Most of stakeholders' concerns clustered around the need to improve collaborative care tools and care facilitators and providers' comfort and abilities to treat behavioral health issues in the primary care setting. CONCLUSIONS: Although stakeholders generally recognize the value of collaborative care in overcoming barriers to care, their perspectives about the utility of different tools varied. The extent to which collaborative care mechanisms are well understood, navigated, and implemented by providers, care facilitators, and patients is critical to the success of the model. Improving the design of the web-based therapy tools, increasing the frequency of team meetings and case presentations, and expanding training for primary care providers on screening and treatment for PTSD and depression and the collaborative care model's structure, processes, and offerings may improve stakeholder perceptions and usage of collaborative care.

Posttraumatic Stress Disorder in U.S. Military Primary Care: Trajectories and Predictors of One-Year Prognosis.

We examined the longitudinal course of primary care patients in the active duty Army with posttraumatic stress disorder (PTSD) and identified prognostic indicators of PTSD severity. Data were drawn from a 6-site randomized trial of collaborative primary care for PTSD and dpression in the military. Subjects were 474 soldiers with PTSD (scores ≥ 50 on the PTSD Checklist -Civilian Version). Four assessments were completed at U.S. Army installations: baseline, and follow-ups at 3 months (92.8% response rate [RR]), 6 months (90.1% RR), and 12 months (87.1% RR). Combat exposure and 7 validated indicators of baseline clinical status (alcohol misuse, depression, pain, somatic symptoms, low mental health functioning, low physical health functioning, mild traumatic brain injury) were used to predict PTSD symptom severity on the Posttraumatic Diagnostic Scale (Cronbach's α = .87, .92, .95, .95, at assessments 1-4, respectively). Growth mixture modeling identified 2 PTSD symptom trajectories: subjects reporting persistent symptoms (Persisters, 81.9%, n = 388), and subjects reporting improved symptoms (Improvers 18.1%, n = 86). Logistic regression modeling examined baseline predictors of symptom trajectories, adjusting for demographics, installation, and treatment condition. Subjects who reported moderate combat exposure, adjusted odds ratio (OR) = 0.44, 95% CI [0.20, 0.98], or who reported high exposure, OR = 0.39, 95% CI [0.17, 0.87], were less likely to be Improvers. Other baseline clinical problems were not related to symptom trajectories. Findings suggested that most military primary care patients with PTSD experience persistent symptoms, highlighting the importance of improving the effectiveness of their care. Most indicators of clinical status offered little prognostic information beyond the brief assessment of combat exposure.

Centrally Assisted Collaborative Telecare for Posttraumatic Stress Disorder and Depression Among Military Personnel Attending Primary Care: A Randomized Clinical Trial.

IMPORTANCE: It is often difficult for members of the US military to access high-quality care for posttraumatic stress disorder (PTSD) and depression. OBJECTIVE: To determine effectiveness of a centrally assisted collaborative telecare (CACT) intervention for PTSD and depression in military primary care. DESIGN, SETTING, AND PARTICIPANTS: The STEPS-UP study (Stepped Enhancement of PTSD Services Using Primary Care) is a randomized trial comparing CACT with usual integrated mental health care for PTSD or depression. Patients, mostly men in their 20s, were enrolled from 18 primary care clinics at 6 military installations from February 2012 to August 2013 with 12-month follow-up completed in October 2014. INTERVENTIONS: Randomization was to CACT (n = 332) or usual care (n = 334). The CACT patients received 12 months of stepped psychosocial and pharmacologic treatment with nurse telecare management of caseloads, symptoms, and treatment. MAIN OUTCOMES AND MEASURES: Primary outcomes were severity scores on the PTSD Diagnostic Scale (PDS; scored 0-51) and Symptom Checklist depression items (SCL-20; scored 0-4). Secondary outcomes were somatic symptoms, pain severity, health-related function, and mental health service use. RESULTS: Of 666 patients, 81% were male and the mean (SD) age was 31.1 (7.7) years. The CACT and usual care patients had similar baseline mean (SD) PDS PTSD (29.4 [9.4] vs 28.9 [8.9]) and SCL-20 depression (2.1 [0.6] vs 2.0 [0.7]) scores. Compared with usual care, CACT patients reported significantly greater mean (SE) 12-month decrease in PDS PTSD scores (-6.07 [0.68] vs -3.54 [0.72]) and SCL-20 depression scores -0.56 [0.05] vs -0.31 [0.05]). In the CACT group, significantly more participants had 50% improvement at 12 months compared with usual care for both PTSD (73 [25%] vs 49 [17%]; relative risk, 1.6 [95% CI, 1.1-2.4]) and depression (86 [30%] vs 59 [21%]; relative risk, 1.7 [95% CI, 1.1-2.4]), with a number needed to treat for a 50% improvement of 12.5 (95% CI, 6.9-71.9) and 11.1 (95% CI, 6.2-50.5), respectively. The CACT patients had significant improvements in somatic symptoms (difference between mean 12-month Patient Health Questionnaire 15 changes, -1.37 [95% CI, -2.26 to -0.47]) and mental health-related functioning (difference between mean 12-month Short Form-12 Mental Component Summary changes, 3.17 [95% CI, 0.91 to 5.42]), as well as increases in telephone health contacts and appropriate medication use. CONCLUSIONS AND RELEVANCE: Central assistance for collaborative telecare with stepped psychosocial management modestly improved outcomes of PTSD and depression among military personnel attending primary care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01492348.

Factors Affecting Mental Health Service Utilization Among California Public College and University Students.

OBJECTIVE: Unmet need for mental health treatment among college students is a significant public health issue. Despite having access to campus mental health providers and insurance to cover services, many college students do not receive necessary services. This study examined factors influencing college students' use of mental health services. METHODS: Online survey data for 33,943 students and 14,018 staff and faculty at 39 college campuses in California were analyzed by using logistic regressions examining the association between students' use of mental health services and student characteristics, campus environment, and the presence of a formal network of campus mental health clinics. RESULTS: Nineteen percent of students reported current serious psychological distress in the past 30 days, and 11% reported significant mental health-related academic impairment in the past year. Twenty percent reported using mental health services while at their current college, 10% by using campus services and 10% off-campus services. Students on campuses with a formal network of mental health clinics were more likely than students at community colleges to receive mental health services (odds ratio [OR] range=1.68-1.69), particularly campus services (OR=3.47-5.72). Students on campuses that are supportive of mental health issues were more likely to receive mental health services (OR=1.22), particularly on campus (OR=1.65). Students with active (versus low) coping skills were consistently more likely to use mental health services. CONCLUSIONS: Establishing more campus mental health clinics, fostering supportive campus environments, and increasing students' coping skills may reduce unmet need for mental health services among college students.

Mental Health Utilization Patterns During a Stepped, Collaborative Care Effectiveness Trial for PTSD and Depression in the Military Health System.

BACKGROUND: Integrated health care models aim to improve access and continuity of mental health services in general medical settings. STEPS-UP is a stepped, centrally assisted collaborative care model designed to improve posttraumatic stress disorder (PTSD) and depression care by providing the appropriate intensity and type of care based on patient characteristics and clinical complexity. STEPS-UP demonstrated improved PTSD and depression outcomes in a large effectiveness trial conducted in the Military Health System. The objective of this study was to examine differences in mental health utilization patterns between patients in the stepped, centrally assisted collaborative care model relative to patients in the collaborative care as usual-treatment arm. METHODS: Patients with probable PTSD and/or depression were recruited at 6 large military treatment facilities, and 666 patients were enrolled and randomized to STEPS-UP or usual collaborative care. Utilization data acquired from Military Health System administrative datasets were analyzed to determine mental health service use and patterns. Clinical complexity and patient characteristics were based on self-report questionnaires collected at baseline. RESULTS: Compared with the treatment as usual arm, STEPS-UP participants received significantly more mental health services and psychiatric medications across primary and specialty care settings during the year of their participation. Patterns of service use indicated that greater clinical complexity was associated with increased service use in the STEPS-UP group, but not in the usual-care group. CONCLUSIONS: Results suggest that stepped, centrally assisted collaborative care models may increase the quantity of mental health services patients receive, while efficiently matching care on the basis of the clinical complexity of patients.

Barriers to Engaging Service Members in Mental Health Care Within the U.S. Military Health System.

OBJECTIVE: Over the past decade, there has been growing recognition of the mental health consequences associated with deployment and service by military service personnel. This study examined potential barriers to mental health care faced by members of the military in accessing needed services. METHODS: This qualitative study of stakeholders was conducted across six large military installations, encompassing 18 Army primary care clinics, within the context of a large randomized controlled trial. Stakeholders included patients recruited for the study (N=38), health care providers working within site clinics (N=31), and the care managers employed to implement the intervention protocol (N=7). RESULTS: Issues raised across stakeholder groups fell into two main categories: structural factors associated with the Army medical system and institutional attitudes and cultural issues across the U.S. military. Structural issues included concerns about the existing capacity of the system, for example, the number of providers available to address the population's needs and the constraints on clinic hours and scheduling practices. The institutional attitude and cultural issues fell into two main areas: attitudes and perceptions by the leadership and the concern that those attitudes could have negative career repercussions for those who access care. CONCLUSIONS: Although there have been significant efforts to improve access to mental health care, stakeholders within the military health system still perceive significant barriers to care. Efforts to ensure adequate and timely access to high-quality mental health care for service members will need to appropriately respond to capacity constraints and organizational and institutional culture.

RAND's Silent Monitoring Protocol for Assessing Suicide Crisis Line Call Content and Quality.

This article describes the methods for developing and testing a silent monitoring protocol for California suicide crisis call centers to evaluate call content and quality, document staff strengths and weaknesses, and identify areas for further training.