Department of Defense Management, Naval Postgraduate School, Monterey, California.
National Bureau of Economic Research, Cambridge, Massachusetts.
JAMA Netw Open. 2024 Sep 3;7(9):e2434246. doi: 10.1001/jamanetworkopen.2024.34246.
Active duty service members have higher mental health stress and cannot choose where to live. It is imperative to understand how geographic access may be associated with their ability to obtain mental health treatment and how the COVID-19 pandemic was associated with these patterns.
To identify changes in the prevalence and intensity of mental health care use when service members experienced changes in core mental health clinician (defined to include psychiatrists, psychiatric nurse practitioners, clinical psychologists and social workers, and marriage and family therapists) capacity in their communities and whether patterns changed from before to after the onset of the COVID-19 pandemic.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study of the active duty population between January 1, 2016, and December 31, 2022, was conducted using individual fixed-effects models to estimate changes in the probability of mental health care visits and visit volume when a person moved across communities with adequate core mental health clinician capacity (≥1 clinician/6000 beneficiaries), shortage areas (<1 clinician/6000 beneficiaries), and areas with 0 clinicians within a 30-minute drive time. All US active duty service members stationed in the continental US, Hawaii, and Alaska were included. Data were analyzed from January through July 2024.
The first set of outcomes captured the probability of making at least 1 mental health care visit in a given quarter; the second set of outcomes captured the intensity of visits (ie, the number of visits log transformed).
This study included 33 039 840 quarterly observations representing 2 461 911 unique active duty service members from the Army, Navy, Marines, and Air Force (1 959 110 observations among Asian or Pacific Islander [5.9%], 5 309 276 observations among Black [16.1%], 5 287 168 observations among Hispanic [16.0%], and 18 739 827 observations among White [56.7%] individuals; 27 473 563 observations among males [83.2%]; mean [SD] age, 28.20 [7.78] years). When an active duty service member moved from a community with adequate capacity at military treatment facilities to one with 0 clinicians within a 30-minute drive, the probability of a mental health visit to any clinician decreased by 1.13 percentage points (95% CI, -1.21 to -1.05 percentage points; equivalent to a 11.6% relative decrease) and the intensity of total visits was reduced by 7.7% (95% CI, -9.0% to -6.5%). The gap increased from before to after the onset of the COVID-19 pandemic, from 8.5% (equivalent to -0.82 percentage points [95% CI, -0.92 to -0.73 percentage points]) to 16.2% (equivalent to -1.58 percentage points [95% CI, -1.70 to -1.46 percentage points]) in the probability of visiting any clinician type for mental health.
In this study, active duty personnel assigned to locations without core military mental health clinicians within a 30-minute drive time were less likely to obtain mental health care and had fewer mental health care visits than those in communities with adequate military mental health capacity even if there was adequate coverage from the civilian sector. The care disparity increased after the onset of the COVID-19 pandemic.
现役军人面临更高的心理健康压力，且无法选择居住地。了解地理可达性如何与其获得心理健康治疗的能力相关，以及 COVID-19 大流行如何影响这些模式，这一点至关重要。
确定当服务成员经历其社区核心心理健康临床医生（定义为包括精神科医生、精神科护士从业者、临床心理学家和社会工作者以及婚姻和家庭治疗师）能力发生变化时，心理健康护理使用的流行率和强度的变化，以及这些模式是否在 COVID-19 大流行之前和之后发生变化。
设计、设置和参与者：本研究回顾性队列研究了 2016 年 1 月 1 日至 2022 年 12 月 31 日期间的现役人员，使用个体固定效应模型来估计当一个人从有足够核心心理健康临床医生能力（≥1 名临床医生/6000 名受益人）、短缺地区（<1 名临床医生/6000 名受益人）或 30 分钟车程内没有任何临床医生的社区转移时，心理健康护理就诊的可能性和就诊量的变化。所有驻扎在美国大陆、夏威夷和阿拉斯加的美国现役服务成员均包括在内。数据分析于 2024 年 1 月至 7 月进行。
第一组结果捕捉了在给定季度至少进行 1 次心理健康护理就诊的概率；第二组结果捕捉了就诊强度（即对数变换后的就诊次数）。
本研究包括 33039840 个季度观察值，代表来自陆军、海军、海军陆战队和空军的 2461911 名现役服务成员（595110 个观察值来自亚洲或太平洋岛民[5.9%]，5309276 个观察值来自黑人[16.1%]，5287168 个观察值来自西班牙裔[16.0%]，18739827 个观察值来自白人[56.7%]；27473563 个观察值来自男性[83.2%]；平均[标准差]年龄为 28.20[7.78]岁）。当现役服务成员从有足够军事治疗设施的社区转移到 30 分钟车程内没有任何临床医生的社区时，任何临床医生的心理健康就诊概率下降了 1.13 个百分点（95%置信区间，-1.21 至-1.05 个百分点；相当于 11.6%的相对减少），总就诊量减少了 7.7%（95%置信区间，-9.0%至-6.5%）。这种差距从 COVID-19 大流行之前到之后有所增加，从 8.5%（相当于-0.82 个百分点[95%置信区间，-0.92 至-0.73 个百分点]）增加到 16.2%（相当于-1.58 个百分点[95%置信区间，-1.70 至-1.46 个百分点]），即任何类型的临床医生为心理健康就诊的概率。
在这项研究中，与有足够军事心理健康能力的社区相比，被分配到 30 分钟车程内没有核心军事心理健康临床医生的现役人员获得心理健康护理的可能性较低，就诊次数也较少，即使有足够的民用部门覆盖。这种护理差距在 COVID-19 大流行之后有所增加。
