Barriers to Engaging Service Members in Mental Health Care Within the U.S. Military Health System Terri Tanielian, M.A., Mahlet A. Woldetsadik, M.P.H., M.Phil., Lisa H. Jaycox, Ph.D., Caroline Batka, M.P.A., Shaela Moen, B.S.N., M.P.H., Carrie Farmer, Ph.D., Charles C. Engel, M.D., M.P.H. 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 con- ducted 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 re- percussions 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 organi- zational and institutional culture. Psychiatric Services in Advance (doi: 10.1176/appi.ps.201500237) There is growing recognition of the mental health conse- quences associated with deployment and service among military service personnel (1). Several studies document the prevalence of mental health problems in the military (2–5) and highlight the potential barriers that members of the military may face in accessing mental health services (6–8). As the primary source of health care for service members, the military health system (MHS) bears special responsibility in addressing these issues. With 9.6 million beneficiaries, 56 medical centers, and 360 ambulatory care clinics, the MHS represents one of the largest health systems in the United States. Primary care has been referred to as the de facto mental health system (9–11). Over the past two decades, multiple efforts have been implemented in health systems to integrate behavioral health into primary care settings. Often referred to as “collaborative care,” the goal of these initiatives is to integrate and improve the mental health services that are delivered in primary care. Common components of these models include efforts to prepare the practice setting by training providers in behavioral health issues; use of a team approach, most often involving a care manager for engaging patients, improving their adherence to treatment, and assessing treatment response; and use of strategies to enhance the in- terface between specialists and primary care (12). In the MHS, service members have an average of three encounters per year in primary care (13). There have been several attempts to integrate behavioral health services into primary care settings and line units in the MHS. In 2007, the Army began integrating mental health services into all of its primary care clinics, including the colocation of mental health specialists and the use of nurse care managers (14,15). In 2013, it expanded the assignment of trained behavioral health clinicians to line units and troop medical clinics. These efforts were intended to expand access to behavioral health specialty providers and reduce soldier concerns with seeking help. Despite these efforts, concerns about access to and quality of mental health treatment within the MHS persist (1,16). This qualitative study was designed to understand stake- holder experiences regarding treatment of posttraumatic stress disorder (PTSD) and depression in Army primary care clinics PS in Advance ps.psychiatryonline.org 1 ARTICLES