'Goodbye and good luck': the mental health needs and treatment experiences of British ex-service personnel

Recognition and treatment of psychological disorders during military service in the UK armed forces: a study of war pensioners

PURPOSE

Little is known about the detection and treatment of psychological disorders arising during military service. We investigated whether personnel who developed disorders while serving in the UK armed forces came to the attention of medical services for these problems, received corresponding diagnoses, and were treated.

METHODS

For this retrospective record-based study 132 veterans in receipt of a war pension for psychological or physical problems received a lifetime diagnostic interview. Those with onsets of PTSD, depression, or alcohol abuse while in service were compared with those who never developed any condition or only developed it after discharge. Their medical records were inspected for contemporaneous contacts, diagnoses, and treatment.

RESULTS

PTSD and depression, but not alcohol abuse, were independently associated with mental health contacts while in service. The median time from PTSD onset to first contact was 1 month. Under half of personnel meeting criteria for these disorders received a corresponding diagnosis, and alcohol abuse was more likely to be recognised in the context of comorbid PTSD. PTSD was as well recognised in earlier as in later years covered by the study. Most personnel with disorders received treatment, and those treated were more likely to be medically downgraded or discharged.

CONCLUSIONS

War pensioners are more likely than not to have had their psychological problems acknowledged and treated while in service. The fact that these problems are still largely present 10 years later raises questions over the continuity of care associated with the transition to civilian life.

Military veterans with mental health problems: a protocol for a systematic review to identify whether they have an additional risk of contact with criminal justice systems compared with other veterans groups

BACKGROUND

There is concern that some veterans of armed forces, in particular those with mental health, drug or alcohol problems, experience difficulty returning to a civilian way of life and may subsequently come into contact with criminal justice services and imprisonment. The aim of this review is to examine whether military veterans with mental health problems, including substance use, have an additional risk of contact with criminal justice systems when compared with veterans who do not have such problems. The review will also seek to identify veterans' views and experiences on their contact with criminal justice services, what contributed to or influenced their contact and whether there are any differences, including international and temporal, in incidence, contact type, veteran type, their presenting health needs and reported experiences.

METHODS/DESIGN

In this review we will adopt a methodological model similar to that previously used by other researchers when reviewing intervention studies. The model, which we will use as a framework for conducting a review of observational and qualitative studies, consists of two parallel synthesis stages within the review process; one for quantitative research and the other for qualitative research. The third stage involves a cross study synthesis, enabling a deeper understanding of the results of the quantitative synthesis. A range of electronic databases, including MEDLINE, PsychINFO, CINAHL, will be systematically searched, from 1939 to present day, using a broad range of search terms that cover four key concepts: mental health, military veterans, substance misuse, and criminal justice. Studies will be screened against topic specific inclusion/exclusion criteria and then against a smaller subset of design specific inclusion/exclusion criteria. Data will be extracted for those studies that meet the inclusion criteria, and all eligible studies will be critically appraised. Included studies, both quantitative and qualitative, will then undergo stage-specific analysis and synthesis. The final stage will combine the findings of both syntheses to enable new understandings of why, how, and by how much, military veterans with mental health problems, including problematic drug and alcohol use, come into contact with the criminal justice system.

Prevalence of DSM-IV major depression among U.S. military personnel: meta-analysis and simulation

A meta-analysis of 25 epidemiological studies estimated the prevalence of recent Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) major depression (MD) among U.S. military personnel. Best estimates of recent prevalence (standard error) were 12.0% (1.2) among currently deployed, 13.1% (1.8) among previously deployed, and 5.7% (1.2) among never deployed. Consistent correlates of prevalence were being female, enlisted, young (ages 17-25), unmarried, and having less than a college education. Simulation of data from a national general population survey was used to estimate expected lifetime prevalence of MD among respondents with the sociodemographic profile and none of the enlistment exclusions of Army personnel. In this Simulated sample, 16.2% (3.1) of respondents had lifetime MD and 69.7% (8.5) of first onsets occurred before expected age of enlistment. Numerous methodological problems limit the results of the meta-analysis and simulation. The article closes with a discussion of recommendations for correcting these problems in future surveillance and operational stress studies.

Anxiety and depression in Marines sent to war in Iraq and Afghanistan

Although the effects of combat deployment on posttraumatic stress disorder have been extensively studied, little is known about the effects of combat deployment on depression and anxiety. This study examined the factors associated with anxiety and depression in a sample of 1560 US Marines who were deployed to Iraq and Afghanistan. Eleven demographic and psychosocial factors were studied in relation to depression and anxiety. Five factors emerged as significant in relation to depression: deployment-related stressors, combat exposure, attitudes toward leadership, mild traumatic brain injury symptoms, and marital status. The same factors, with the exception of marital status, emerged as significant in relation to anxiety. Deployment-related stressors had a stronger association with both depression and anxiety than any other variable, including combat exposure. This finding is important because deployment-related stressors are potentially modifiable by the military.

Self-harm and attempted suicide among UK armed forces personnel: results of a cross-sectional survey

AIMS

Little has been reported on self-harm among the UK Armed Forces, partly due to the difficulties in recording self-harm, within an often-difficult-to-reach population. This study assesses the lifetime prevalence of attempted suicide and self-harm within currently serving and ex-service personnel of the UK Armed Forces.

METHODS

Telephone interviews were conducted with 821 personnel who had previously participated in the King's Centre for Military Health Research military health study. Within the telephone interview, participants were asked about attempted suicide and episodes of self-harm.

RESULTS

A lifetime prevalence of 5.6% for intentional self-harm (self-harm or attempted suicide) was reported. Intentional self-harm was associated with psychological morbidity (in particular, post-traumatic stress disorder) and adverse experiences in childhood. Ex-service personnel reported lifetime prevalence more than double that of serving personnel (10.5% vs 4.2%, respectively). Participants reporting intentional self-harm were younger (34.4 years vs 39.8 years).

CONCLUSION

A lifetime prevalence of 5.6% for attempted suicide and self-harm is higher than previous research has suggested. Younger service personnel, those who have experienced adversity in childhood, those with other psychological morbidity, and ex-service personnel are more likely to report self-harm behaviours.

Military hierarchy, job stress and mental health in peacetime

BACKGROUND

Most studies of mental health in the armed forces focus primarily on post-traumatic stress disorders among military personnel in combat situations.

AIMS

To evaluate the prevalence of common mental disorders (CMD) and job stress, and the association between the two, among military personnel in peacetime. Additionally, it sought to identify occupational subgroups with higher prevalences of CMD.

METHODS

The study participants were 506 military personnel from a Brazilian army directorate in Rio de Janeiro City. CMD were evaluated using the 12-item version General Health Questionnaire. Job characteristics were measured using the effort-reward imbalance (ERI) model and by categories of military rank. Prevalence ratios (PRs) were estimated by Poisson regression to obtain robust (95%) confidence intervals (CIs).

RESULTS

The prevalence of CMD was 33% (95% CI 29-37). After adjusting for age, education, income, lifestyle and other occupational characteristics, ERI was associated with CMD (PR = 2.03; 95% CI 1.3-3.1). Overcommitment proved to be an important component of job stress. Independently of socio-economic, demographic, lifestyle and job stress variables, the rank of lieutenant associated strongly with CMD (PR = 2.02; 95% CI 1.2-4 0.1).

CONCLUSIONS

This study found that job stress among armed forces personnel is associated with CMD. In addition, the specific occupational characteristics of the military environment can lead to a higher prevalence of CMD among those holding the rank of lieutenant.

Trauma, identity and mental health in UK military veterans

BACKGROUND

Military service can lead to profound changes in identity, both in servicemen's perception of themselves and in their relationship to the world, but the significance of these changes for psychopathology is unclear. We investigated whether the extent and valence of identity change was related to the degree of military trauma exposure or to post-traumatic stress disorder (PTSD) and suicide attempts. We further sought to describe the nature of such changes using qualitative analysis.

METHOD

A total of 153 veterans in receipt of a war pension for PTSD or physical disability were identified. Interviews established retrospectively DSM-IV diagnoses of PTSD and reports of suicidal ideation or behaviour since enlistment were examined.

RESULTS

Trauma exposure alone was unrelated to any measure of identity change. By contrast, PTSD was associated with a relationship to the world that had changed in a negative direction. It was also associated with a changed perception of self, which could be either positive or negative. After controlling for trauma exposure and PTSD, suicidal behaviours were associated with more negative perceptions of the world. These perceptions of the world included disillusionment about human nature and a more specific rejection of civilian life.

CONCLUSIONS

PTSD and suicidal behaviours in veterans seem not to be associated with significantly more negative views of the self but rather with more alienation from civilian life. This has serious consequences for engaging veterans in National Health Service (NHS) mental health services and for the provision of effective treatment.

The costs of conflict: meeting the mental health needs of serving personnel and service veterans

Military mental health has, until recently, been a neglected and marginalized area of interest and although both World Wars saw important advances, in peacetime we typically forget lessons learned in earlier conflicts. Since 2003 however, with high intensity war-fighting on two fronts involving the service personnel of many nations, attention has, once again focused on the immediate and long-term emotional and psychological impact of combat. Whilst we know a lot about posttraumatic stress disorder (PTSD), much less attention has been paid to a variety of other equally, if not more salient yet superficially less dramatic problems facing service personnel deployed on operations, but which are much more likely to lead to mental disorder than traumatic events and the 'horrors of war'. This article describes some of these broader yet less tangible and under-researched issues and discusses the provision of services for the burgeoning veteran community. The mental health of service personnel and veterans is politically sensitive and attracts significant public and media interest. Understanding and responding appropriately to the needs of this group should be of concern to all mental health professionals and it has important consequences, not only for affected individuals but, for the public perception of mental health services as a whole.

Assessing the performance of the short screening scale for post‐traumatic stress disorder in a large nationally‐representative survey

The performance of the short screening scale for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM‐IV) post‐traumatic stress disorder (PTSD), has not been assessed in an independent general population sample, although it has been used in epidemiological as well as clinical research. In this report we evaluate the short screening scale in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a population‐based survey of US household and group quarter residents. DSM‐IV PTSD was assessed via symptom questions in the Alcohol Use Disorder and Associated Disabilities Interview Schedule‐DSM‐IV (AUDADIS‐IV) version. Sensitivity, specificity, positive and negative predictive value, and percent correctly classified were calculated, using the interview‐based diagnosis as the standard. Replicating findings from the initial report, a score of four or more on the short screening scale identifies cases of PTSD with sensitivity of 78%, specificity of 97%, positive predictive value of 75%, and negative predictive value of 98%. The percentage of correctly classified respondents was 96%. The findings support the utility of the seven‐item scale for screening PTSD in clinical and general population samples.

The stigma of mental health problems and other barriers to care in the UK Armed Forces

Background

As with the general population, a proportion of military personnel with mental health problems do not seek help. As the military is a profession at high risk of occupational psychiatric injury, understanding barriers to help-seeking is a priority.

Method

Participants were drawn from a large UK military health study. Participants undertook a telephone interview including the Patient Health Questionnaire (PHQ); a short measure of PTSD (Primary Care PTSD, PC-PTSD); a series of questions about service utilisation; and barriers to care. The response rate was 76% (821 participants).

Results

The most common barriers to care reported are those relating to the anticipated public stigma associated with consulting for a mental health problem. In addition, participants reported barriers in the practicalities of consulting such as scheduling an appointment and having time off for treatment. Barriers to care did not appear to be diminished after people leave the Armed Forces. Veterans report additional barriers to care of not knowing where to find help and a concern that their employer would blame them for their problems. Those with mental health problems, such as PTSD, report significantly more barriers to care than those who do not have a diagnosis of a mental disorder.

Conclusions

Despite recent efforts to de-stigmatise mental disorders in the military, anticipated stigma and practical barriers to consulting stand in the way of access to care for some Service personnel. Further interventions to reduce stigma and ensuring that Service personnel have access to high quality confidential assessment and treatment remain priorities for the UK Armed Forces.

Mental health and health service use among post-national service veterans: results from the 2007 Adult Psychiatric Morbidity Survey of England

BACKGROUND

There is concern surrounding the psychological health and uptake of treatment services among veterans of the UK Armed Forces.

METHOD

Data from a cross-sectional, nationally representative sample were used to compare health outcomes and treatment seeking among 257 post-national service veterans aged 16-64 years and 504 age and sex frequency-matched non-veterans living in the community in England. Early leavers (<4 years service) were compared with longer serving veterans.

RESULTS

Male veterans reported more childhood adversity and were more likely to have experienced a major trauma in adulthood than non-veterans. There was no association between any measure of mental health and veteran status in males, except reporting more violent behaviours [adjusted odds ratio (aOR) 1.44, 95% confidence interval (CI) 1.01-2.06]. In females, a significant association was found between veteran status and ever having suicidal thoughts (aOR 2.82, 95% CI 1.13-7.03). No differences in treatment-seeking behaviour were identified between veterans and non-veterans with any mental disorder. Early service leavers were more likely to be heavy drinkers (aOR 4.16, 95% CI 1.08-16.00), to have had suicidal thoughts (aOR 2.37, 95% CI 1.21-4.66) and to have self-harmed (aOR 12.36, 95% CI 1.61-94.68) than longer serving veterans.

CONCLUSIONS

The findings of this study do not suggest that being a veteran is associated with adversity in terms of mental health, social disadvantage or reluctance to seek treatment compared with the general population. Some evidence implies that early service leavers may experience more mental health problems than longer-serving veterans.

Assessing the mental health consequences of military combat in Iraq and Afghanistan: a literature review

The aim of this paper was to explore how a military career may affect the mental health of serving and ex-service personnel, to identify the accessibility and helpfulness of support (both during and after military service) and to make recommendations for change. A literature search was undertaken using the MetaFind meta search engine with keywords: mental health, psychological health, emotional health, soldier, British army, army, ex-army, military, military personnel, armed forces, resettlement, impact, family relationship, divorce, health, support services. The search was applied to the following databases: EBSCO Host, CINAHL, Cochrane Library, Ingenta Connect, Medline, PsyArticles, PubMed, Web of Knowledge, together with the specific journals American Journal of Psychiatry, British Journal of Psychiatry and ProQuest Nursing journals. 110 relevant publications were identified and from these 61 papers were retrieved for further analysis. Poor mental health is associated with increased risk of social exclusion on leaving the services, which further exacerbates mental health problems. An increasing number of ex-service personnel are expected to develop stress-related mental health problems in the future.

Does trauma risk management reduce psychological distress in deployed troops?

BACKGROUND

Military personnel exposed to potentially traumatic events whilst deployed on operational duties may develop psychological problems. The Royal Marines have made extensive use of Trauma Risk Management (TRiM), a peer-support system that operates through practitioners embedded within operational units. TRiM aims to promote recognition of psychological illness and to facilitate social support.

AIMS

To evaluate the effects of TRiM in two units at different stages of implementation.

METHODS

Royal Marines and Army personnel were surveyed prior to, during and upon return from an operational deployment to Afghanistan. Participants completed measures of general mental health (GHQ12) and traumatic stress [PCL(C)].

RESULTS

We received responses from 180 pre-deployment, 105 during deployment and 137 post-deployment. Personnel within units with experience of TRiM reported lower levels of psychological distress than personnel in the unit who were using TRiM for the first time. Both groups reported higher psychological distress scores before and during deployment, compared with post-deployment. However, we found personnel who reported having more access to social support during deployment reported less psychological distress.

CONCLUSIONS

The use of TRiM may assist in increasing the psychological resilience of military personnel through the facilitation of social support; this may have particular utility during operational deployments.

Help-seeking and receipt of treatment among UK service personnel

BACKGROUND

For armed forces personnel, data on help-seeking behaviour and receipt of treatment for mental disorders are important for both research and policy.

AIMS

To examine mental healthcare service use and receipt of treatment in a sample of the UK military.

METHOD

Participants were drawn from an existing UK military health cohort. The sample was stratified by reserve status and by participation in the main war-fighting period of the Iraq War. Participants completed a telephone-based structured diagnostic interview comprising the Patient Health Questionnaire and Primary Care Post-Traumatic Stress Disorder Screen (PC-PTSD), and a series of questions about service utilisation and treatment receipt.

RESULTS

Only 23% of those with common mental disorders and still serving in the military were receiving any form of medical professional help. Non-medical sources of help such as chaplains were more widely used. Among regular personnel in receipt of professional help, most were seen in primary care (79%) and the most common treatment was medication or counselling/psychotherapy. Few regular personnel were receiving cognitive-behavioural therapy (CBT). These findings are comparable with those reported for the general population.

CONCLUSIONS

In the UK armed forces, the majority of those with mental disorders are not currently seeking medical help for their symptoms. Further work to understand barriers to care is important and timely given that this is a group at risk of occupational psychiatric injury.

Do stigma and other perceived barriers to mental health care differ across Armed Forces?

OBJECTIVES

Military organizations are keen to address barriers to mental health care yet stigma and barriers to care remain little understood, especially potential cultural differences between Armed Forces. The aim of this study was to compare data collected by the US, UK, Australian, New Zealand and Canadian militaries using Hoge et al.'s perceived stigma and barriers to care measure (Combat duty in Iraq and Afghanistan, mental health problems and barriers to care. New Engl J Med 2004;351:13-22).

DESIGN

Each member country identified data sources that had enquired about Hoge et al.'s perceived stigma and perceived barriers to care items in the re-deployment or immediate post-deployment period. Five relevant statements were included in the study.

SETTING

US, UK Australian, New Zealand and Canadian Armed Forces.

RESULTS

Concerns about stigma and barriers to care tended to be more prominent among personnel who met criteria for a mental health problem. The pattern of reported stigma and barriers to care was similar across the Armed Forces of all five nations.

CONCLUSIONS

Barriers to care continue to be a major issue for service personnel within Western military forces. Although there are policy, procedural and cultural differences between Armed Forces, the nations studied appear to share some similarities in terms of perceived stigma and barriers to psychological care. Further research to understand patterns of reporting and subgroup differences is required.

A prospective study of depression following combat deployment in support of the wars in Iraq and Afghanistan

OBJECTIVE

We investigated relations between deployment and new-onset depression among US service members recently deployed to the wars in Iraq and Afghanistan.

METHODS

We included 40 219 Millennium Cohort Study participants who completed baseline and follow-up questionnaires and met inclusion criteria. Participants were identified with depression if they met the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire criteria for depression at follow-up, but not at baseline.

RESULTS

Deployed men and women with combat exposures had the highest onset of depression, followed by those not deployed and those deployed without combat exposures. Combat-deployed men and women were at increased risk for new-onset depression compared with nondeployed men and women (men: adjusted odds ratio [AOR]=1.32; 95% confidence interval [CI]=1.13, 1.54; women: AOR=2.13; 95% CI=1.70, 2.65). Conversely, deployment without combat exposures led to decreased risk for new-onset depression compared with those who did not deploy (men: AOR=0.66; 95% CI=0.53, 0.83; women: AOR=0.65; 95% CI=0.47, 0.89).

CONCLUSIONS

Deployment with combat exposures is a risk factor for new-onset depression among US service members. Post-deployment screening may be beneficial for US service members exposed to combat.

Prevalence Estimates of Combat-Related PTSD: A Critical Review

The aim of the present study was to provide a critical review of prevalence estimates of combat-related post-traumatic stress disorder (PTSD) among military personnel and veterans, and of the relevant factors that may account for the variability of estimates within and across cohorts, including methodological and conceptual factors accounting for differences in prevalence rates across nations, conflicts/wars, and studies. MEDLINE and PsycINFO databases were examined for literature on combat-related PTSD. The following terms were used independently and in combinations in this search: PTSD, combat, veterans, military, epidemiology, prevalence. The point prevalence of combat-related PTSD in US military veterans since the Vietnam War ranged from approximately 2% to 17%. Studies of recent conflicts suggest that combat-related PTSD afflicts between 4% and 17% of US Iraq War veterans, but only 3-6% of returning UK Iraq War veterans. Thus, the prevalence range is narrower and tends to have a lower ceiling among combat veterans of non-US Western nations. Variability in prevalence is likely due to differences in sampling strategies; measurement strategies; inclusion and measurement of the DSM-IV clinically significant impairment criterion; timing and latency of assessment and potential for recall bias; and combat experiences. Prevalence rates are also likely affected by issues related to PTSD course, chronicity, and comorbidity; symptom overlap with other psychiatric disorders; and sociopolitical and cultural factors that may vary over time and by nation. The disorder represents a significant and costly illness to veterans, their families, and society as a whole. Further carefully conceptualized research, however, is needed to advance our understanding of disorder prevalence, as well as associated information on course, phenomenology, protective factors, treatment, and economic costs.

The prevalence of common mental disorders and PTSD in the UK military: using data from a clinical interview-based study

BACKGROUND

The mental health of the Armed Forces is an important issue of both academic and public interest. The aims of this study are to: a) assess the prevalence and risk factors for common mental disorders and post traumatic stress disorder (PTSD) symptoms, during the main fighting period of the Iraq War (TELIC 1) and later deployments to Iraq or elsewhere and enlistment status (regular or reserve), and b) compare the prevalence of depression, PTSD symptoms and suicidal ideation in regular and reserve UK Army personnel who deployed to Iraq with their US counterparts.

METHODS

Participants were drawn from a large UK military health study using a standard two phase survey technique stratified by deployment status and engagement type. Participants undertook a structured telephone interview including the Patient Health Questionnaire (PHQ) and a short measure of PTSD (Primary Care PTSD, PC-PTSD). The response rate was 76% (821 participants).

RESULTS

The weighted prevalence of common mental disorders and PTSD symptoms was 27.2% and 4.8%, respectively. The most common diagnoses were alcohol abuse (18.0%) and neurotic disorders (13.5%). There was no health effect of deploying for regular personnel, but an increased risk of PTSD for reservists who deployed to Iraq and other recent deployments compared to reservists who did not deploy. The prevalence of depression, PTSD symptoms and subjective poor health were similar between regular US and UK Iraq combatants.

CONCLUSION

The most common mental disorders in the UK military are alcohol abuse and neurotic disorders. The prevalence of PTSD symptoms remains low in the UK military, but reservists are at greater risk of psychiatric injury than regular personnel.

Suicide after leaving the UK armed forces--a cohort study

BACKGROUND

Few studies have examined suicide risk in individuals once they have left the military. We aimed to investigate the rate, timing, and risk factors for suicide in all those who had left the UK Armed Forces (1996-2005).

METHODS AND FINDINGS

We carried out a cohort study of ex-Armed Forces personnel by linking national databases of discharged personnel and suicide deaths (which included deaths receiving either a suicide or undetermined verdict). Comparisons were made with both general and serving populations. During the study period 233,803 individuals left the Armed Forces and 224 died by suicide. Although the overall rate of suicide was not greater than that in the general population, the risk of suicide in men aged 24 y and younger who had left the Armed Forces was approximately two to three times higher than the risk for the same age groups in the general and serving populations (age-specific rate ratios ranging from 170 to 290). The risk of suicide for men aged 30-49 y was lower than that in the general population. The risk was persistent but may have been at its highest in the first 2 y following discharge. The risk of suicide was greatest in males, those who had served in the Army, those with a short length of service, and those of lower rank. The rate of contact with specialist mental health was lowest in the age groups at greatest risk of suicide (14% for those aged under 20 y, 20% for those aged 20-24 y).

CONCLUSIONS

Young men who leave the UK Armed Forces were at increased risk of suicide. This may reflect preservice vulnerabilities rather than factors related to service experiences or discharge. Preventive strategies might include practical and psychological preparation for discharge and encouraging appropriate help-seeking behaviour once individuals have left the services.

The mental health of veterans

For the majority service in the Armed Forces is beneficial and, in the main, military veterans have successful lives. However, a minority have a bleaker outlook as a result of on-going ill health and social exclusion. Whilst the media focuses on Post Traumatic Stress Disorder, in reality the most frequent mental health problems for veterans are alcohol problems, depression and anxiety disorders. These difficulties are difficult to manage as veterans, particularly those who are unwell, demonstrate a reticence to seek help for mental health problems. Another issue is that many veterans are now reserve personnel who have been found to be at greater risk of developing mental health problems than their regular counterparts. Steps to improve the knowledge and expertise of primary care services about veteran's mental health issues and increasing the availability of treatment options are important and are underway.

Stigma and the military: evaluation of a PTSD psychoeducational program

Trauma risk management (TRiM) is an intensive posttraumatic stress disorder (PTSD) psychoeducational management strategy based on peer-group risk assessment developed by the UK Royal Navy (RN). TRiM seeks to modify attitudes about PTSD, stress, and help-seeking and trains military personnel to identify at-risk individuals and refer them for early intervention. This quasiexperimental study found that TRiM training significantly improved attitudes about PTSD, stress, and help-seeking from TRiM-trained personnel. There was a nonsignificant effect on attitudes to seeking help from normal military support networks and on general health. Within both the military and civilian populations, stigma is a serious issue preventing help-seeking and reducing quality of life. The results suggest that TRiM is a promising antistigma program within organizational settings.

Gulf War Illness: lessons from medically unexplained symptoms

Service in the Persian Gulf in 1991 is associated with increased reporting of symptoms and distress in a proportion of those who served there. Yet despite clear evidence of an increase in symptom burden and a decrease in well being, exhaustive clinical and laboratory based scientific research has failed to document many reproducible biomedical abnormalities in this group. Likewise, there has been no evidence of an increase in disease related mortality. Formal psychiatric disorders are twice as common in Gulf War veterans, as might be expected in the aftermath of any conflict, but this too is insufficient to explain the ill-health observed. Many service personnel who returned unwell believe that they have Gulf War Syndrome, and that their ill-health is due to exposures that they encountered in theatre. Research on multiple exposures to date has not generated a plausible aetiological mechanism for veterans' ill-health. Even if medical research has failed to provide a satisfactory explanation, it remains the case that many of those affected continue to be unwell and disabled some 15 years after returning from combat. For this reason, it is time that more attention is given to developing effective interventions to relieve their ill-health and distress. In this review we discuss the importance of the wider social context, individual illness beliefs and attributions and go on to outline a model of continuing ill-health in Gulf veterans. The review concludes with some suggestions for future research priorities, in particular the need for further qualitative studies to further our understanding of the illness, in order that better treatments may be developed.

Predictors of general medical and psychological treatment use among a national sample of peacekeeping veterans with health problems

We investigated general medical and psychological treatment use predictors among peacekeeping veterans with health problems, aiming to find those characteristics most associated with treatment use intensity (i.e., visit counts). One thousand one hundred and thirty-two male Canadian Forces peacekeeping veterans registered with Veterans Affairs for health problems were randomly recruited for a prospective national survey. Regression analyses for treatment use intensity controlled for age, total time deployed and health problems (covariates), and examined the incremental contribution of depression and post-traumatic stress disorder (PTSD) severity on health service use intensity. Results revealed that after controlling for covariates, the depression and PTSD model was associated with increased medical and psychological treatment use intensity. Medical use intensity was significantly predicted by married status, greater depression and health problems; psychological treatment use intensity was predicted by younger age, greater PTSD severity and health problems. This study highlights the importance of an integrated primary care-mental health service delivery model for veterans.

Consent, confidentiality, and the Data Protection Act

Overly strict interpretation of the law is hampering epidemiological research. Here, one research team shows why regulators and organisations holding data should adjust their approach

Risk, psychiatry and the military

The relationship between combat and psychiatric breakdown has been well recognised for decades. The change to smaller, professional armed forces has reduced the risk of large-scale acute psychiatric casualties, and should have led to a corresponding decrease in long-term ill health, but this expected reduction seems not to have happened. Likewise, attempts at preventing psychiatric injury, by screening before deployment or debriefing after, have been disappointing. Three reasons for this are proposed: a rethinking of the relationship between trauma and long-term outcome, catalysed by the attempts of US society to come to terms with the Vietnam conflict; a broadening of the scope of psychiatric injury as it moved to the civilian sector; and the increased prominence of unexplained syndromes and contested diagnoses such as Gulf War syndrome. Traditional psychiatric injury is predictable, proportionate and can, in theory, be managed. These newer forms of injury are in contrast unanticipated, paradoxical, ill understood and hard to manage. Traditional approaches to risk management by reducing exposure have not been successful, and may increase risk aversion and reduce resilience. However, the experiences of civilians in wartime or the military show that people are not intrinsically risk-averse, provided they can see purpose in accepting risk.