Coming Home: Social Functioning and the Mental Health of UK Reservists on Return From Deployment to Iraq or Afghanistan

Post-traumatic stress disorder in peacekeepers: a systematic literature review and meta-analysis

Background: In peacekeeping operations, soldiers are often exposed to the same traumatic factors as in conventional war and may also be subject to physical risks and psychological stressors associated with post-traumatic stress disorder (PTSD). According to the Conservation of Resources Theory (COR), PTSD stems from resource depletion and inadequate restoration.Objectives: To discuss and meta-analyse PTSD-related factors among peacekeepers, based on the COR theory, framing them as resources or loss/threat of loss of resources.Methods: A systematic literature search was performed with relevant keywords, 51 articles were reviewed and 21 of them meta-analysed.Results: Factors mentioned in prior reviews, reinforced by ours, include: family/community and military support as resources; single marital status, female gender, serving in infantry, and longer time since deployment as lack of resources. Factors mentioned in prior reviews, confirmed by our meta-analysis, include: education, rank, and problem-focused coping as resources; negative perceptions about deployment, combat/trauma exposure, deployment stressors, and deployment duration as lack of resources. Factors overlooked in prior reviews include: age as a resource; negative life events, and negative social interactions as lack of resources. Comorbidities include: physical health problems, post-deployment impact on functioning, and post-deployment psychopathology (e.g., depression, substance use).Conclusions: Significantly more individual than contextual factors were identified. While some factors inherent to missions (e.g., combat exposure, deployment stressors) cannot be mitigated, others are crucial to prevent peacekeepers' PTSD (e.g., coping strategies, deployment duration, perceptions about deployment, social interactions, support during deployment) and to inform selection and monitoring by the Armed Forces (e.g., pre-, during and post-deployment psychopathology). However, the findings should be interpreted with caution due to limitations (e.g., publication bias, study heterogeneity) that may have affected the generalizability and strength of the recommendations.

Universal, school-based transdiagnostic interventions to promote mental health and emotional wellbeing: a systematic review

OBJECTIVE

This systematic review aims to evaluate the effectiveness of universal school-based transdiagnostic interventions in promoting the mental health of children and adolescents. It compares and discusses interventions targeting the prevention of mental disorders versus the promotion of mental health. Additionally, the roles of teachers and psychologists as intervention conductors are examined.

METHODS

A comprehensive search of the Psycinfo, Pubmed, and Web of Science databases was conducted without any time restrictions to identify relevant literature on universal school-based transdiagnostic interventions promoting children and adolescents' mental health.

RESULTS AND DISCUSSION

The findings reveal that universal school-based transdiagnostic promotion/prevention programs have a small to medium overall effect size. These interventions demonstrate a broad coverage of different aspects of children and adolescents' mental health. However, the relative effectiveness of teacher-led versus psychologist-led interventions remains unclear. Interventions focused on preventing mental disorders exhibit a higher effect size, albeit on a narrower range of mental health aspects for children and adolescents.

SIGNIFICANCE

This study enhances our understanding of universal school-based transdiagnostic interventions and their impact on children and adolescents' mental health. Further research is needed to elucidate the comparative efficacy of teacher-led and psychologist-led interventions and to explore the specific dimensions of mental health targeted by these interventions.

Work-related factors and the risk of common mental disorder 1 year later: A prospective cohort study among junior doctors

OBJECTIVE

This study investigated the relationship between work-related factors at baseline and the risk of common mental disorder at 12 month follow-up among a cohort of junior doctors.

METHOD

The data comprised the junior doctor respondents from two annual waves of the 'Medicine in Australia: Balancing Employment and Life' (MABEL) survey, a national longitudinal cohort of Australian doctors. Individual and work-related risk factors were assessed at baseline and the mental health outcome of caseness of common mental disorder (CMD) was assessed using the 6-item Kessler Psychological Distress Scale at 12-month follow-up. Unadjusted and adjusted logistic regressions were conducted to estimate the association between each baseline variable and the likelihood of CMD caseness at follow-up 1 year later.

RESULTS

Among 383 junior doctors, 24 (6%) had CMD 1 year later. Five work-related baseline variables were significantly associated with a higher likelihood of CMD 1 year later in adjusted models; lack of social support in work location (odds ratios (OR) = 6.11; 95% confidence intervals (CI) = [2.52, 14.81]), work-life imbalance (OR = 4.50; 95% CI = [1.31, 15.46]), poor peer support network in the workplace (OR = 2.61; 95% CI = [1.08, 6.27]), perceptions of patient expectations (OR = 2.46; 95% CI = [1.06, 5.71]) and total weekly work hours (OR 1.04; 95% CI = [1.01, 1.07]; p = 0.002)in models adjusting for gender.

CONCLUSION

These results identify key modifiable work-related factors that are associated with junior doctors' future mental health. Our findings suggest the need for a greater focus upon interpersonal factors and work-life balance in multi-level interventions while continuing to address workplace and system-level factors to prevent future mental disorder in junior doctors.

Reintegration of crisis services employees: a systematic literature review

Purpose

Crisis services personnel are frequently deployed around the globe under highly demanding conditions. This raises the need to better understand the deployment process and more especially, sustainable reintegration after deployment. Despite recent research efforts, the study of the post-deployment stage, more specifically the reintegration process, remains fragmented and limited. To address these limitations, this review aims at (1) describing how reintegration is conceptualised and measured in the existing literature, (2) identifying what dimensions are associated with the reintegration process and (3) identifying what we know about the process of reintegration in terms of timing and phases.

Design/methodology/approach

Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) protocol, the authors identified 5,859 documents across several scientific databases published between 1995 and 2021. Based on predefined eligibility criteria, 104 documents were yielded.

Findings

Research has primarily focused on descriptive studies of negative individual and interpersonal outcomes after deployment. However, this review indicates that reintegration is dynamic, multi-sector, multidimensional and dual. Each of its phases and dimensions is associated with distinct challenges.

Originality/value

To the authors’ knowledge, this is the first research that investigates reintegration among different crisis services and provides an integrative social-ecological framework that identifies the different dimensions and challenges of this process.

Protecting the health of responders: Team Health

The rise in humanitarian disasters has led to more volunteers responding to deploy with humanitarian organisations. Those organisations that use these volunteers have a responsibility for the health of these teams of workers. This personal view outlines the three phases of 'Team Health'-prepare, sustain and recover. This is a paper commissioned as a part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

Factor analysis of the Personality Assessment Inventory in service members with traumatic brain injury

PRIMARY OBJECTIVE

To identify the factor structure of the Personality Assessment Inventory (PAI) clinical scales for military service members with traumatic brain injury (TBI).

RESEARCH DESIGN

Retrospective analysis of existing data base.

METHODS AND PROCEDURES

The sample included 210 service members with TBI who completed the PAI as part of a neuropsychological evaluation at a military TBI clinic. Statistical analysis included exploratory factor analysis of 214 items of the 11 PAI clinical scales.

MAIN OUTCOMES AND RESULTS

Exploratory factor analysis indicated a four-factor solution accounting for 30.4% of the variance in scores. A review of the face validity of the items from each factor generated the following factor labels: Somatic/Psychiatric/Cognitive Distress, Social Distress, Substance Misuse, and Depression.

CONCLUSIONS

The PAI appears to assess general distress (i.e., somatic/psychiatric/cognitive) and substance misuse constructs for both psychiatric and TBI populations, but it also appears to assess a "social distress" construct (i.e., difficulties socializing in both military and civilian populations) that is unique to military populations. Suggestions are offered to re-conceptualize PAI clinical scales specific to psychopathology (i.e., schizophrenia, paranoia, mania, borderline, antisocial) and personality disorders (i.e., borderline, antisocial) in terms of neurologic and military specific issues for service members with TBI.

Social isolation and loneliness of UK veterans: a Delphi study

BACKGROUND

Evidence increasingly acknowledges the impact of social isolation and loneliness on the lives of military veterans and the wider Armed Forces Community.

AIMS

The study gathered expert consensus to (i) understand if veterans are considered 'unique' in their experiences of social isolation and loneliness; (ii) examine perceived factors leading to social isolation and loneliness of veterans; (iii) identify ways to tackle veterans' social isolation and loneliness.

METHODS

This study adopted a three-phase Delphi method. Phase 1 utilized a qualitative approach and Phase 2 and Phase 3 utilized a mixed-methods approach.

RESULTS

Several outcomes were identified across the three phases. Transition out of the military was viewed as a period to build emotional resilience and raise awareness of relevant services. It was also concluded that veterans would benefit from integrating into services within the wider community, and that social prescribing services could be a vehicle to link veterans to relevant services. Furthermore, access to, and the content of, programmes was also of importance.

CONCLUSIONS

These findings illustrate various important interventional aspects to consider when funding and implementing programmes focussed on tackling social isolation and loneliness.

A Retrospective Study of Demographic, Medical, and Psychological Predictors of Readiness in Service Members With Mild Traumatic Brain Injury

INTRODUCTION

Given the significant number of service members who have incurred mild traumatic brain injury (TBI) over the past two decades, this study was completed to determine the relative contribution of demographic, TBI-related, and psychological factors that predict the readiness of service members with primarily mild TBI.

METHODS AND MATERIALS

This retrospective study included 141 service members who were evaluated at an outpatient military TBI rehabilitation clinic. Information regarding demographics, TBI-related variables, and psychological factors was collected and entered into hierarchical multinomial logistic regressions to predict military work status. Demographic predictor variables included age, race, gender, rank, service branch; TBI-specific variables including time since injury and neuropsychological variables (i.e., Wechsler Adult Intelligence Scale-IV (WAIS-IV) Full Scale Intelligence Quotient (FSIQ) and Processing Speed Indices; California Verbal Learning Test-IV total recall t-score); and psychiatric variables including concomitant psychiatric diagnoses and Personality Assessment Inventory indices. The outcome variable was the service member's military work status (i.e., return to duty (RTD); Medical Evaluation Board-disabled (MEB); retired) at time of discharge from the TBI clinic.

RESULTS

Statistical analyses indicated that the total model predicted 31% of the variance in work status, with demographics predicting 16% of the variance, concomitant psychiatric diagnoses and WAIS-IV FSIQ predicting an additional 12%, and subjective somatic/psychological distress (Personality Assessment Inventory indices) predicting an additional 3%. Regarding the primary groups of interest (i.e., RTD vs. MEB), stepwise regressions indicated that those who RTD have higher intelligence and report less physical/psychological distress than the disabled group.

CONCLUSIONS

In general, those service members who were able to RTD versus those who were classified as disabled (MEB) were of higher IQ and reported less somatic/psychological distress. Of note, traditional indices of TBI severity did not predict the ability of the sample to RTD. The results suggest the importance of treating psychological conditions and identifying possible indicators of resilience (e.g., higher intelligence) to increase the readiness of service members with mild TBI.

Predicting military readiness using objective and subjective indices of neuropsychological impairment in service members with mild traumatic brain injury

The military is interested in identifying factors to improve the readiness of service members with traumatic brain injury (TBI). TBI outcome studies have primarily used objective neuropsychological data interpreted using the absolute level of functioning (i.e., high average, average, low average), though research suggests it is also important to consider other objective indices of the relative degree of decline (e.g., mild, moderate, severe) and subjective complaints. The current study determined the predictive ability of objective indices of neuropsychological functioning (i.e., absolute level and the relative degree of decline) and subjective complaints (i.e., Neurobehavioral Symptom Inventory) in terms of military work status (i.e., return to duty, medically disabled, retired) for 113 service members with mild TBI. ANOVAs and post-hoc tests indicated individuals who were able to return to duty had higher absolute indices and lower relative decline scores in working memory and overall intelligence, as well as lower subjective neuropsychological complaints when compared to those who were disabled or retired. Multinomial logistic regression models generally supported these findings, except relative decline scores were not predictive of military work status likely due to issues of collinearity (i.e., relative decline scores are calculated using absolute scores). In conclusion, indices of absolute functioning and subjective neuropsychological impairments appear to be predictors of the ability to return to duty post-TBI in military populations, emphasizing the need to focus on cognitive reserve and emotional resilience as potential interventions.

Childhood determinants of past-year anxiety and depression in recently transitioned military personnel

BACKGROUND

Anxiety and depression may hamper a smooth transition from military to civilian life and may be important predictors of longer-term health and functioning. However, it is as yet unclear to what extent they are determined by childhood factors in a recently transitioned population.

METHODS

We utilised logistic regression and Generalised Structural Equation Modelling to analyse associations of ICD-10 past-year anxiety and depression with childhood trauma and disorder in a recently transitioned population using detailed interview data from the ADF (Australian Defence Force) Transition and Wellbeing Research Programme.

RESULTS

Past-year anxiety (including PTSD) was prevalent (36.4%, 95% CI, 31.9-41.1) and associated with childhood anxiety (but not other types of childhood disorder), childhood interpersonal trauma (but not other childhood trauma) and adult-onset trauma. Childhood anxiety had a direct and significant association with past-year anxiety. The pathway between childhood interpersonal trauma and past-year anxiety was fully mediated by childhood anxiety. Past-year depression was less prevalent (11.3%, 95% CI, 8.7-14.5) and had no association with childhood disorder or trauma variables.

LIMITATIONS

The main predictor variables utilized in this analysis were childhood experiences recalled from adulthood, thus rendering the responses vulnerable to autobiographical bias.

CONCLUSIONS

Past-year anxiety was highly prevalent in the period of transition and had strong associations with childhood and military factors, suggesting predictability and potentially preventability.

Mental disorders and medical conditions associated with causing injury or death: A population-based study

The aim of the present study is to examine mental disorders and medical conditions associated with causing harm to another person in the general adult population. The sample (n=22,138) was drawn from a cross-sectional survey designed to characterize mental health needs in France. Twelve-month DSM-IV axis I mental disorders and medical conditions, and lifetime occurrence of potentially traumatic events were assessed with the Composite International Diagnostic Interview-SF Overall, 2% (n=430) of the sample reported having injured or killed someone. Causing harm was associated with male gender, lower education level, and being unemployed. The great majority (85%) of those who caused harm had experienced two or more additional potentially traumatic events. When adjusting for gender, employment status, education and number of events experienced, causing harm was associated with certain anxiety disorders, drug dependence and lifetime suicide attempt but not with major depression or post-traumatic stress disorder. Furthermore, causing harm was not associated with medical conditions in multivariate analyses. These results highlight the need for clinicians to be particularly attentive to the psychological burden that may be experienced by those who have harmed or killed someone.

Psychosocial factors associated with psychological distress and functional difficulties in recently transitioned and current serving regular Australian Defence Force members

The transition period from military-to-civilian life can be one of the most significant and stressful periods in the military life cycle. We explore the psychosocial factors associated with psychological distress and functional impairment among those who recently transitioned from the Australian Defence Force (ADF) and those currently serving in 2015. Using data from the Transition and Wellbeing Research Programme, multinomial logistic regression models were used to analyze the associations between a combined measure of psychological distress and functional impairment (K10/SDS) with various psychosocial, lifestyle, and physical health factors. There were 10,210 in the final analytic cohort (Transitioned=3,254; Regular 2015 ADF=6,956). Overall, the odds of belonging to the highly distressed/impaired group were greatest among those with insomnia (Odds Ratio 18.53), low resilience (OR 7.67), physical health symptoms (OR 7.16), and alcohol risk (OR 4.67). Other factors included pain (OR 3.36), financial issues (OR 2.38), and social strain (OR 1.98). The associations with insomnia and physical health symptoms were stronger among the Transitioned compared to the Regular 2015 ADF. Results of this research highlights the importance of taking a multi-dimensional perspective of symptoms in military populations, particularly in those recently transitioned from permanent service, as predictors of future risk of disorder.

Outcomes from a One-Week Adapted Sport and Adapted Adventure Recovery Programme for Military Personnel

Background: The Battle Back Centre offers a bespoke, Self Determination Theory-oriented adapted sport and adventurous training programme centred on experiential learning and reflection to support the recovery of military personnel. Aim: To identify the short-term impact of participation in the programme on positive mental health and psychological need satisfaction. Method: Participants were 978 wounded, injured and sick (WIS) personnel classified as: Wounded (battle casualties), Injured (non-battle casualties) and Sick (mental/physical illness). Participants completed the Basic Need Satisfaction in General Scale (Gagné, 2003) and Warwick and Edinburgh Mental Well Being Scale (Tennant et al. 2006) on arrival and course completion. Results: All measures of positive mental health and psychological need satisfaction showed statistically significant increases, with a large effect size, from baseline to course completion (mean ± SD change in positive mental health, competence, autonomy and relatedness were 7.19 ± 9.61, 0.46 ± 0.9, 0.27 ± 0.84, 0.26 ± 0.86, respectively, p < 0.05). While the average magnitude of the intervention effect for positive mental health (16%) is comparable or greater than other reported interventions, changes were achieved in a shorter time. Conclusion: Findings highlight the positive short-term effect adapted sport and adventurous activities have for WIS personnel. Declaration of interest: Work supported by The Royal British Legion.

The return of the traumatized army veteran: a qualitative study of UK ex-servicemen in the aftermath of war, 1945 to 2000

The challenge of transition from service to civilian life is explored through the experiences of a sample of 225 UK army veterans between 1945 and 2000. All subjects had a war pension for a psychological disorder, and most had served overseas in combat roles. Statements about issues of adjustment and health were analyzed by the constant comparison method. Although 20 themes were identified, three ('anxiety, nerves and depression', 'enduring illness attributed to combat exposure', and 'illness interferes with the ability to find or keep employment') accounted for 46% of the total and were reported by between 53% and 86% of subjects. Consistency was observed in the ranking of themes over time. In content, they replicate those reported by veterans of recent conflicts, suggesting that the core issues of transition have an enduring quality. Most statements (66%) date from the 1940s, a time when the application process for a pension required the veteran to provide an explanation for his illness. A rise in the number of statements during the 1980s and 1990s reflected wider cultural acceptance of post-traumatic illness and veteran population entering retirement with time to reflect on defining experiences.

Does perceived ostracism contribute to mental health concerns among veterans who have been deployed?

Posttraumatic stress-negative psychological experiences as a result of traumatic stressors-can hinder military veterans' reintegration into society and cause various mental health problems. Veterans need quality social relationships to facilitate reintegration and to cope with posttraumatic stress and related mental health problems; discrimination or other forms of interpersonal rejection can exacerbate these veterans' problems. Ostracism (i.e., being ignored and excluded) is a painful and psychologically distressing experience that may be one factor that contributes to the problems of veterans who are dealing with posttraumatic stress. To our knowledge, this connection has yet to be tested empirically. Thus, we investigated the correlation between posttraumatic stress, perceived ostracism, and other theoretically relevant variables (i.e., mental health problems, perceived social support, psychological need satisfaction) in a sample of veterans who have had at least one deployment. Our results provide preliminary empirical evidence suggesting that perceived ostracism may contribute to veteran' deployment-related psychological problems. Veterans' perceived ostracism correlated with psychological problems (i.e., posttraumatic stress symptoms, anxiety and psychological distress), and it explained additional variance in posttraumatic stress symptoms above and beyond common predictors of these symptoms (i.e., deployment stress, perceived military and civilian-based social support). Finally, perceived ostracism emerged as the most important predictor of posttraumatic stress symptoms in a relative weights analysis.

Associations of Stress Exposures and Social Support With Long-Term Mental Health Outcomes Among U.S. Iraq War Veterans

The long-term mental health effects of war-zone deployment in the Iraq and Afghanistan wars on military personnel are a significant public health concern. Using data collected prospectively at three distinct assessments during 2003-2014 as part of the Neurocognition Deployment Health Study and VA Cooperative Studies Program Study #566, we explored how stress exposures prior, during, and after return from deployment influence the long-term mental health outcomes of posttraumatic stress disorder (PTSD), depression, anxiety disorders, and problem drinking. Longer-term mental health outcomes were assessed in 375 service members and military veterans an average of 7.5 years (standard deviation = 1.0 year) after the initial (i.e., "index") Iraq deployment following their predeployment assessment. Anxiety disorder was the most commonly observed long-term mental health outcome (36.0%), followed by depression (24.5%), PTSD (24.3%), and problem drinking (21.0%). Multivariable regression models showed that greater postdeployment stressors, as measured by the Post-Deployment Life Events scale, were associated with greater risk of depression, anxiety disorders, and problem drinking. Anxiety disorder was the only outcome affected by predeployment stress concerns. In addition, greater postdeployment social support was associated with lower risk of all outcomes except problem drinking. These findings highlight the importance of assessing postdeployment stress exposures, such as stressful or traumatic life events, given the potential impact of these stressors on long-term mental health outcomes. This study also highlights the importance of postdeployment social support as a modifiable protective factor that can be used to help mitigate risk of long-term adverse mental health outcomes following war-zone exposure.

Deployment of personnel to military operations: impact on mental health and social functioning

This Campbell systematic review examines the effects of deployment on mental health. The review summarizes evidence from 185 studies. All studies used observational data to quantify the effect of deployment. This review includes studies that evaluate the effects of deployment on mental health. A total of 185 studies were identified. However, only 40 of these were assessed to be of sufficient methodological quality to be included in the final analysis. The studies spanned the period from 1993 to 2017 and were mostly carried out in the USA, UK and Australia. The studies all had some important methodological weaknesses. None of the included studies used experimental designs (random assignment). Deployment to military operations negatively affects the mental health functioning of deployed military personnel. For assessments taken more than 24 months since exposure, we consistently found adverse effects of deployment on all mental health domains (PTSD, depression, substance abuse/dependence, and common mental disorders), particularly on PTSD. For assessments taken less than 24 months (or a variable number of months since exposure) the evidence was less consistent and in many instances inconclusive.

Plain language summary

Deployment to military operations negatively affects the mental health functioning of deployed military personnel: While additional research is needed, the current evidence strongly supports the notion that deployment negatively affects mental health functioning of deployed military personnel.What is this review about?: When military personnel are deployed to military operations abroad they face an increased risk of physical harm, and an increased risk of adverse shocks to their mental health.The primary condition under consideration is deployment to an international military operation. Deployment to a military operation is not a uniform condition; rather, it covers a range of scenarios. Military deployment is defined as performing military service in an operation at a location outside the home country for a limited time period, pursuant to orders.The review included studies that reported outcomes for individuals who had been deployed. This review looked at the effect of deployment on mental health outcomes. The mental health outcomes are: post-traumatic stress disorder (PTSD), major depressive disorder (MDD), common mental disorders (depression, anxiety and somatisation disorders) and substance-related disorders.By identifying the major effects of deployment on mental health and quantifying these effects, the review can inform policy development on deployment and military activity as well as post-deployment support for veterans. In this way the review enables decision-makers to prioritise key areas.What are the main findings of this review?: What studies are included?: This review includes studies that evaluate the effects of deployment on mental health. A total of 185 studies were identified. However, only 40 of these were assessed to be of sufficient methodological quality to be included in the final analysis. The studies spanned the period from 1993 to 2017 and were mostly carried out in the USA, UK and Australia. The studies all had some important methodological weaknesses. None of the included studies used experimental designs (random assignment).Does deployment have an effect on mental health?: Deployment to military operations negatively affects the mental health functioning of deployed military personnel. For assessments taken more than 24 months since exposure, we consistently found adverse effects of deployment on all mental health domains (PTSD, depression, substance abuse/dependence, and common mental disorders), particularly on PTSD. For assessments taken less than 24 months (or a variable number of months since exposure) the evidence was less consistent and in many instances inconclusive.What do the findings of this review mean?: The odds of screening positive for PTSD and depression were consistently high in the longer term. This suggests that efforts should be increased to detect and treat mental disorders, as effects may be long-lasting.Overall the risk of bias in the majority of included studies was high. While it is difficult to imagine a randomised study design to understand how deployment affects mental health, other matters such as changes to personnel policy, or unanticipated shocks to the demand for military personnel, could potentially be a rich source of quasi-experimental variation.How up-to-date is this review?: The review authors searched for studies up to 2017. This Campbell systematic review was published in March 2018.

Executive summary

BACKGROUND: When military personnel are deployed to military operations abroad they face an increased risk of physical harm, and an increased risk of adverse shocks to their mental health. Research suggests that the increased risk to mental health is mainly due to the hazards of war, combat exposure: firing weapons, road side bombs, seeing fellow soldiers, friends, civilians, and enemies being injured, maimed or killed. These experiences may lead to severe mental stress. The adverse impact on mental health is the psychological cost of war, and it is of interest to policymakers to learn the magnitude of these effects. This review sets out to synthesise available evidence about the consequences of deployment for deployed military personnel in the mental health and social functioning domains.OBJECTIVES: The objective of this review isto synthesise the consequences of deployment to military operation on the mental health and social functioning of deployed military personnel.SEARCH METHODS: We searched electronic databases, grey literature, and references from primary studies and related reviews. No language or date restrictions were applied to the searches. We searched the following electronic databases: Academic Search Elite, Cochrane Library, EMBASE, ERIC, MEDLINE, PsycINFO, Science Citation Index, Social Science Citation Index, SocINDEX, as well as the Nordic platforms: bibliotek.dk, BIBSYS, and LIBRIS. The conclusions of this review are based on the most recent searches performed. The last search was performed in April 2017.SELECTION CRITERIA: Primary studies had to meet the following inclusion criteria: Participants: The participants should be military personnel.Intervention: The condition should be deployment to a military operation.Comparison: The relevant comparisons were either comparing a) deployed military personnel to non-deployed military personnel, b) deployed military personnel to military personnel deployed elsewhere, for example personnel deployed to non-combat operations, c) military personnel deployed to the same operation but stratified by combat exposure.Outcomes: The study should report on one or more mental health outcomes, and/or social functioning for the deployed participants. In particular studies should report on one or more of the following mental health outcomes: PTSD, major depression, substance abuse or dependence (including alcohol), and common mental disorders (depression and anxiety disorders). The following social functioning outcomes were relevant: employment, and homelessness.Study Designs: Both experimental and quasi-experimental designs with a comparison group were eligible for inclusion in the review. Studies were excluded if they: Reported on deployments taking place before 1989.Used a within group pre-post study design.Did not report on at least one of the mental health or social functioning outcomes. DATA COLLECTION AND ANALYSIS: The total number of potentially relevant studies constituted31,049records. A total of 185 studies met the inclusion criteria and were critically appraised by the review authors. The final selection of 185 studies was from 13 different countries.Forty eight of the 185 studies did not report effect estimates or provide data that would allow the calculation of an effect size and standard error. Fifty four studies were excluded because of overlapping samples. The majority of those studies were from USA but the main reason for not using studies from USA in the synthesis was lack of information to calculate an effect size. Nearly half the studies from the UK could not be used in the synthesis due to overlap of data samples. Forty three studies were judged to have a very high risk of bias (5 on the scale) and, in accordance with the protocol, we excluded these from the data synthesis on the basis that they would be more likely to mislead than inform., Thus a total of 40 studies, from five different countries, were included in the data synthesis.Random effects models were used to pool data across the studies. We used the odds ratio. Pooled estimates were weighted with inverse variance methods, and 95% confidence intervals were calculated. The meta-analyses were carried out by time since exposure (short, medium, long, and other time since exposure) and by type of comparison (deployed versus non-deployed, all deployed but stratified by either combat operations versus non-combat operations, or stratified by combat exposure). We performed single factor subgroup analysis. The assessment of any difference between subgroups was based on 95% confidence intervals. Funnel plots were used to assess the possibility of publication bias. Sensitivity analysis was used to evaluate whether the pooled effect sizes were robust across components of methodological quality.MAIN RESULTS: The findings were mixed, depending on the outcome, the time since exposure and the approach (deployed versus non-deployed termed absolute or stratified by extent of combat termed relative) used to investigate the effect. It was not possible to analyse the outcomes homelessness and employment. All studies that could be used in the data synthesis reported on the impact of deployment on mental health; PTSD, depression, substance use or common mental disorder.For assessments taken less than 24 months since exposure the evidence was inconclusive either because too few studies reported results in the short and medium term and/or the degree of heterogeneity between studies was large.For assessments taken at other time points (a variable number of months since exposure) the evidence was inconclusive for the relative comparisons due to either too few studies or a substantial degree of heterogeneity between studies. For the absolute comparison the analysis of common mental disorder was inconclusive, whereas the average effects of PTSD and depression were positive and statistically significant (PTSD odds ratio (OR) was 1.91 (95% confidence interval (CI): 1.28 to 2.85) and OR=1.98 (95% CI: 1.05 to 3.70) for depression). The analysis concerning substance use indicated that deployed participants did not have higher odds of screening positive for substance use compared to non-deployed participants (OR=1.15 (95% CI: 0.98 to 1.36)).For assessments taken more than 24 months post exposure, meta-analyses indicated that the odds of screening positive for PTSD, depression, substance use and common mental disorder were higher for participants in the deployed group compared to participants in the group that were not deployed (PTSD OR=3.31 (95% CI: 2.69 to 4.07), OR=2.19 (95% CI: 1.58 to 3.03) for depression, OR=1.27 (95% CI: 1.15 to 1.39) for substance use, and OR=1.64 (95% CI: 1.38 to 1.96) for common mental disorder). Likewise, participants reporting high combat exposure had higher odds of screening positive for PTSD and depression than participants reporting lower exposure for long term assessments (PTSD OR=3.05 (95% CI: 1.94 to 4.80) and OR=1.81 (95% CI: 1.28 to 2.56) for depression). The analyses of substance use and common mental disorder were inconclusive due to too few studies.On the basis of the prevalence of mental health problems in pre-deployed or non-deployed population based comparison sampleswe would therefore expect the long term prevalence of PTSD in post-deployed samples to be in the range 6.1 - 14.9%, the long term prevalence of depression to be in the range from 7.6% to 18%, the long term prevalence of substance use to be in the range from 2.4% to 17.5% and the prevalence of common mental disorder to be in the range from 10% to 23%.Sensitivity analyses resulted in no appreciable change in effect size, suggesting that the results are robust.It was only possible to assess the impact of two types of personnel characteristics (branch of service and duty/enlistment status) on the mental health outcomes. We found no evidence to suggest that the effect of deployment on any outcomes differ between these two types of personnel characteristics.AUTHORS' CONCLUSIONS: Deployment to military operations negatively affects the mental health functioning of deployed military personnel. We focused on the effect of deployment on PTSD (post-traumatic stress disorder), depression, substance abuse/dependence, and common mental disorders (depression and anxiety disorders). For assessments taken less than 24 months (or a variable number of months since exposure) the evidence was less consistent and in many instances inconclusive. For assessments taken more than 24 months since exposure, we consistently found adverse effects of deployment on all domains, particularly on PTSD. There is increased political awareness of the need to address post deployment mental health problems. The odds of screening positive for PTSD and depression were consistently high in the longer term. This suggests that efforts should be increased to detect and treat mental disorders, as effects may be long lasting. Mental illness is of particular concern in the military for operational reasons, but they may be hard to detect in the military setting because a military career is intimately linked with mental and physical strength.It was not possible to examine a number of factors which we had reason to expect would impact on the magnitude of the effect. This would have been particularly relevant from a policy perspective because these are direct parameters that one could use to optimally "organize" deployment in order to minimize impacts on mental health functioning.While additional research is needed, the current evidence strongly supports the notion that deployment negatively affects mental health functioning of deployed military personnel. The next step is to begin to examine preventive measures and policies for organizing deployment, in order to minimize the effects on mental health.

Is prevention better than cure? A systematic review of the effectiveness of well-being interventions for military personnel adjusting to civilian life

Exposure to stressful and potentially traumatic experiences is a risk for military personnel and for some this may increase susceptibility to reduced well-being. The aim of this systematic review was to examine the effectiveness of interventions to promote the well-being of military personnel adjusting to civilian life. Electronic databases were searched including MEDLINE, Embase, HMIC, PsycINFO, Pilots and CINAHL. Twelve articles, all conducted in the USA, were included in the review. Articles were synthesised narratively and assessed for bias against established criteria. The studies evaluated the effectiveness of interventions for current and former military personnel. The interventions included expressive writing, anger management, cognitive training, psycho-education, and techniques to promote relaxation, connection in relationships and resilience. Interventions had some significant positive effects mostly for veterans adjusting to civilian life and other family members. There was much heterogeneity in the design and the outcome measures used in the studies reviewed. The review highlights the need for future robust trials examining the effectiveness of well-being interventions in military groups with diverse characteristics; in addition qualitative research to explore a conceptualisation of well-being for this group and the acceptability of interventions which may be perceived as treatment. The results of the review will be of interest to a number of stakeholders in military, public health and mental health settings. PROSPERO Registration number: CRD42015026341.

The influence of psychosocial factors in veteran adjustment to civilian life

AIM

Although most veterans have a successful transition to civilian life when they leave the military, some struggle to cope and adjust to the demands and challenges of civilian life. This study explores how a variety of psychosocial factors influence veteran adjustment to civilian life in Scotland, UK, and which of these factors predict a poor adjustment.

METHODS

One hundred and fifty-four veterans across Scotland completed a set of questionnaires that measured veteran adjustment difficulty, quality of life, mental health, stigma, self-stigma, attitude towards help-seeking, likelihood of help-seeking, experiential avoidance, reappraisal and suppression.

RESULTS

Veteran adjustment difficulty and quality of life were significantly correlated to a number of psychosocial factors. Mental health, experiential avoidance and cognitive reappraisal were found to be predictors of veteran adjustment difficulty, and experiential avoidance and cognitive reappraisal partially mediated the relationship between mental health and veteran adjustment, with experiential avoidance being the stronger mediator.

DISCUSSION

Our findings suggest that early assessment of experiential avoidance and cognitive reappraisal and the provision of relevant emotion regulation skills training could potentially reduce the veteran's need for more complex (and costly) psychological interventions in the future. Implications for veterans, as well as the services and professionals involved with veteran transition and health care are discussed.

A framework to create more mentally healthy workplaces: A viewpoint

Mental illness is now the leading cause of long-term sickness absence among Australian workers, with significant costs to the individual, their employers and society more broadly. However, to date, there has been little evidence-informed guidance as to what workplaces should be doing to enhance their employees' mental health and wellbeing. In this article, we present a framework outlining the key strategies employers can implement to create more mentally healthy workplaces. The five key strategies outlined are as follows: (1) designing work to minimise harm, (2) building organisational resilience through good management, (3) enhancing personal resilience, (4) promoting early help-seeking and (5) supporting recovery and return to work. A narrative review is utilised to outline the theoretical evidence for this framework and to describe the available research evidence for a number of key example interventions for each of the five strategies. While each workplace needs to develop tailored solutions, the five strategy framework proposed in this review will hopefully provide a simple framework for employers and those advising them to use when judging the adequacy of existing services and considering opportunities for further enhancements.

Canine companionship is associated with modification of attentional bias in posttraumatic stress disorder

Attentional bias towards aversive stimuli has been demonstrated in the anxiety disorders and in posttraumatic stress disorder, and attentional bias modification has been proposed as a candidate treatment. This study rigorously assessed attentional bias towards aversive and pleasant visual imagery associated with the presence or absence of a familiar service canine in 23 veterans with chronic military-related posttraumatic stress disorder. Participants were repeatedly tested with and without their service canines present on two tasks designed to elicit spontaneous visual attention to facial and scenic image pairs, respectively. Each stimulus contrasted an emotive image with a neutral image. Via eye-tracking, the difference in visual attention directed to each image was analyzed as a function of the valence contrast and presence/absence of the canine. Across both tasks, the presence of a familiar service canine attenuated the normative attentional bias towards aversive image content. In the facial task, presence of the service canine specifically reduced attention toward angry faces. In that task, as well, accumulated days with the service canine similarly modulated attention toward facial emotion. The results suggest that the presence of a familiar service canine is associated with attenuation of attentional bias to aversive stimuli in chronic military-service-related posttraumatic stress disorder. Questions remain regarding the generalization of such effects to other populations, their dependence on the familiarity, breed, and training of the canine, and on social context.

A systematic review of the usefulness of pre-employment and pre-duty screening in predicting mental health outcomes amongst emergency workers

Despite a lack of proven efficacy, pre-employment or pre-duty screening, which alleges to test for vulnerability to PTSD and other mental health disorders, remains common amongst emergency services. This systematic review aimed to determine the usefulness of different factors in predicting mental disorder amongst emergency workers and to inform practice regarding screening procedures. Systematic searches were conducted in MEDLINE, PsycINFO and EMBASE to identify cohort studies linking pre-employment or pre-duty measures in first responders with later mental health outcomes. Possible predictors of poor mental health were grouped into six categories and their overall level of evidence was assessed. Twenty-one prospective cohort studies were identified. Dynamic measures including physiological responses to simulated trauma and maladaptive coping styles (e.g. negative self-appraisal) had stronger evidence as predictors of vulnerability in first responders than more traditional static factors (e.g. pre-existing psychopathology). Personality factors (e.g. trait anger) had moderate evidence for predictive power. Based on the evidence reviewed, however, we are unable to provide emergency services with specific information to enhance their current personnel selection. The results indicate that pre-duty screening protocols that include personality assessments and dynamic measures of physiological and psychological coping strategies may be able to identify some personnel at increased risk of mental health problems. However, further longitudinal research is required in order to provide meaningful guidance to employers on the overall utility of either pre-employment or pre-duty screening. In particular, research examining the sensitivity, specificity and positive predictive values of various screening measures is urgently needed.

Violent behavior among military reservists

Large numbers of British and American Reservists have been deployed to operations in Iraq and Afghanistan. Little is known about the impact of deployment and combat exposure on violent behavior in Reservists. The purpose of this study was to determine the prevalence of self-reported violent behavior among a representative sample of United Kingdom Reservists, the risk factors associated with violence and the impact of deployment and combat exposure on violence. This study used data from a large cohort study of randomly selected UK military personnel and included Reservists who were in service at the time of sampling (n = 1710). Data were collected by questionnaires that asked about socio-demographic and military characteristics, pre-enlistment antisocial behavior, deployment experiences, post-deployment mental health, and self-reported interpersonal violent behavior. The prevalence of violence among Reservists was 3.5%. Deployment was found to be a risk factor for violent behavior even after adjustment for confounders. The association with violence was similar for those deployed in either a combat role or non-combat role. Violence was also strongly associated with mental health risk factors (PTSD, common mental disorders, and alcohol misuse). This study demonstrated higher levels of self-reported post-deployment violence in UK Reservists who had served in either Iraq or Afghanistan. Deployment, irrespective of the role was associated with higher levels of violent behavior among Reservists. The results also emphasize the risk of violent behavior associated with post-deployment mental health problems. Aggr. Behav. 43:273-280, 2017. © 2016 Wiley Periodicals, Inc.

The mental health of fire-fighters: An examination of the impact of repeated trauma exposure

OBJECTIVE

Emergency workers, such as fire-fighters, are routinely exposed to potentially traumatic events. While a number of studies have examined the occurrence of post-traumatic stress disorder, the role of multiple traumas on other mental health sequelae, such as depression and alcohol misuse, among emergency workers remains unclear. This study aimed to assess the prevalence of post-traumatic stress disorder, depression and alcohol misuse in a sample of current and retired fire-fighters and examine their relationship with cumulative trauma exposure.

METHOD

A cross-sectional survey was completed by current (n = 488) and retired (n = 265) fire-fighters from Fire and Rescue New South Wales, Australia. Demographic and occupational information was collected, including the number of fatal incidents fire-fighters reported attending across years of service. Validated, self-report measures were used to determine probable caseness for post-traumatic stress disorder, depression and heavy drinking.

RESULTS

Among current fire-fighters, rates of post-traumatic stress disorder and depression were 8% and 5%, respectively, while 4% reported consumption of more than 42 alcoholic drinks per week. Retired fire-fighters reported significantly greater levels of symptomatology, with the prevalence estimates of post-traumatic stress disorder at 18% (p = 0.001), depression at 18% (p < 0.001) and heavy drinking at 7%. There was a significant positive linear relationship between the number of fatal incidents attended and rates of post-traumatic stress disorder, depression and heavy drinking.

CONCLUSION

Fire-fighters suffer from high rates of mental disorders, with rates of post-traumatic stress disorder, depression and heavy drinking continuing to rise in a linear manner with each additional trauma exposure. The level of psychiatric morbidity among retired fire-fighters appears to be particularly high. Our findings have important implications for the ongoing debates surrounding the detection of mental disorders in high-risk occupations and for policy considerations around the welfare of current and retired emergency workers.

International military operations and mental health--A review

BACKGROUND

Volunteering in international military missions has been scrutinized for its effects on mental health. Different kinds of exposures to traumatic events are associated with a variety of mental disorders, mainly heightened rates of post-traumatic stress disorder (PTSD) and alcohol abuse.

AIMS

Based on the literature we discuss risk and protective factors concerning the psychological well-being of soldiers attending to international military operations.

METHODS

A systematic literature search was carried out using relevant search terms to identify the articles for this review.

RESULTS AND CONCLUSIONS

The ability to recognize and treat acute stress reactions during deployments is important. Post-deployment psychosocial support and services have a role in lowering barriers to care, diminishing stigma and also in recognizing individuals who suffer from psychological distress or psychiatric symptoms, to connect them with appropriate care. Further investigation of gender differences and the role of stigmatization is warranted. Most of those participating in international military operations are repatriated without problems, but repeated exposure to combat situations and other stressors may affect mental health in various ways. Stigmatization is still a barrier to care.

What happens to the mental health of UK service personnel after they return home from Afghanistan?

OBJECTIVE

Fear et al identified a small but significant increase in probable post-traumatic stress disorder (PTSD) in UK military personnel from around 3% in first year post deployment to around 6% by year 5. As yet it is not clear what factors are linked to the increase in probable PTSD, and therefore, serial measurement of poor mental health would be helpful.

METHOD

Rates of mental ill health among UK service personnel were compared upon deployment completion and at follow-up and identified factors associated with maladjustment.

RESULTS

Poor mental health symptomatology increased from baseline to follow-up, PTSD symptoms and related functional impairment increased significantly. Poor baseline mental health was predictive of transition and family relationship difficulties.

CONCLUSIONS

The results are discussed in relation to encouraging recognition and reporting of symptoms among personnel and their social networks.

Social networks, mental health problems, and mental health service utilization in OEF/OIF National Guard veterans

PURPOSE

Low social support and small social network size have been associated with a variety of negative mental health outcomes, while their impact on mental health services use is less clear. To date, few studies have examined these associations in National Guard service members, where frequency of mental health problems is high, social support may come from military as well as other sources, and services use may be suboptimal.

METHODS

Surveys were administered to 1448 recently returned National Guard members. Multivariable regression models assessed the associations between social support characteristics, probable mental health conditions, and service utilization.

RESULTS

In bivariate analyses, large social network size, high social network diversity, high perceived social support, and high military unit support were each associated with lower likelihood of having a probable mental health condition (p < .001). In adjusted analyses, high perceived social support (OR .90, CI .88-.92) and high unit support (OR .96, CI .94-.97) continued to be significantly associated with lower likelihood of mental health conditions. Two social support measures were associated with lower likelihood of receiving mental health services in bivariate analyses, but were not significant in adjusted models.

CONCLUSIONS

General social support and military-specific support were robustly associated with reduced mental health symptoms in National Guard members. Policy makers, military leaders, and clinicians should attend to service members' level of support from both the community and their units and continue efforts to bolster these supports. Other strategies, such as focused outreach, may be needed to bring National Guard members with need into mental health care.

Prevalence of, risk factors for, and consequences of posttraumatic stress disorder and other mental health problems in military populations deployed to Iraq and Afghanistan

This review summarizes the epidemiology of posttraumatic stress disorder (PTSD) and related mental health problems among persons who served in the armed forces during the Iraq and Afghanistan conflicts, as reflected in the literature published between 2009 and 2014. One-hundred and sixteen research studies are reviewed, most of which are among non-treatment-seeking US service members or treatment-seeking US veterans. Evidence is provided for demographic, military, and deployment-related risk factors for PTSD, though most derive from cross-sectional studies and few control for combat exposure, which is a primary risk factor for mental health problems in this cohort. Evidence is also provided linking PTSD with outcomes in the following domains: physical health, suicide, housing and homelessness, employment and economic well-being, social well-being, and aggression, violence, and criminality. Also included is evidence about the prevalence of mental health service use in this cohort. In many instances, the current suite of studies replicates findings observed in civilian samples, but new findings emerge of relevance to both military and civilian populations, such as the link between PTSD and suicide. Future research should make effort to control for combat exposure and use longitudinal study designs; promising areas for investigation are in non-treatment-seeking samples of US veterans and the role of social support in preventing or mitigating mental health problems in this group.

Medical and Welfare Officers beliefs about post-deployment screening for mental health disorders in the UK Armed Forces: a qualitative study

Background

This study aimed to examine currently serving United Kingdom (UK) military Medical and Welfare Officers views on the potential introduction of post-deployment screening for mental ill health.

Methods

Semi-structured interviews were conducted with 21 Medical and Welfare Officers. Interview transcripts were analysed using data-driven thematic analysis.

Results

Four themes were identified: positive views of screening; reliability of responses; impact on workload; and suggestions for implementation. Interviewees viewed the introduction of screening post-deployment as likely to increase awareness of mental health problems whilst also reporting that service personnel were likely to conceal their true mental health status by providing misleading responses to any screening tool. Concern over reliability of responses may provide one explanation for the reluctance of service personnel to seek help for problems, as they could feel they will not be taken seriously. Welfare Officers felt they would not have the knowledge or experience to respond to help-seeking. Although participants were concerned about potential impact on their personal workload, they indicated a desire to positively engage with the screening programme if research showed it was an effective tool to improve mental health care.

Conclusions

Welfare and healthcare providers are well disposed towards a screening programme for mental health but highlight a few concerns in its implementation. In particular Welfare Officers appear to require more training in how to respond to mental ill health. Concerns about available funding and resources to respond to increased workload will need to be addressed should post-deployment screening for mental health be introduced in the UK military.

Narrative transformation among military personnel on an adventurous training and sport course

In the wake of recent wars, some military personnel face considerable physical and mental health problems. In this article I explore the effects of an adapted sport and inclusive adventurous training course for military personnel who have experienced physical injury and/or psychological trauma. Using a dialogical narrative approach, I analyzed stories shared by six soldiers during the course to explore the effects of involvement. Participation in the course seemed to facilitate a narrative transformation or opening corresponding to a broadening identity and sense of self. Story plots progressed from a failing monological narrative, through a chaos narrative, toward a dialogical quest narrative prioritizing immersion in an intense present, a developing self, and a relational orientation. On the basis of narrative theory, I suggest this transformation holds positive consequences for the health and well-being of military personnel who have experienced injury and/or trauma.

Posttraumatic stress disorder post Iraq and Afghanistan: prevalence among military subgroups

A large body of research has been produced in recent years investigating posttraumatic stress disorder (PTSD) among military personnel following deployment to Iraq and Afghanistan, resulting in apparent differences in PTSD prevalence. We compare prevalence estimates for current PTSD between military subgroups, providing insight into how groups may be differentially affected by deployment. Systematic literature searches using the terms PTSD, stress disorder, and acute stress, combined with terms relating to military personnel, identified 49 relevant papers. Studies with a sample size of less than 100 and studies based on data for treatment seeking or injured populations were excluded. Studies were categorized according to theatre of deployment (Iraq or Afghanistan), combat and noncombat deployed samples, sex, enlistment type (regular or reserve and [or] National Guard), and service branch (for example, army, navy, and air force). Meta-analysis was used to assess PTSD prevalence across subgroups. There was large variability in PTSD prevalence between studies, but, regardless of heterogeneity, prevalence rates of PTSD were higher among studies of Iraq-deployed personnel (12.9%; 95% CI 11.3% to 14.4%), compared with personnel deployed to Afghanistan (7.1%; 95% CI 4.6% to 9.6%), combat deployed personnel, and personnel serving in the Canadian, US, or UK army or the navy or marines (12.4%; 95% CI 10.9% to 13.4%), compared with the other services (4.9%; 95% CI 1.4% to 8.4%). Contrary to findings from within-study comparisons, we did not find a difference in PTSD prevalence for regular active-duty and reserve or National Guard personnel. Categorizing studies according to deployment location and branch of service identified differences among subgroups that provide further support for factors underlying the development of PTSD.

Military unit support, postdeployment social support, and PTSD symptoms among active duty and National Guard soldiers deployed to Iraq

Research suggests that military unit support and community postdeployment social support are associated with fewer PTSD symptoms following military deployment. This study extended prior research by examining the associations among predeployment unit support and PTSD symptoms before Iraq deployment as well as unit support, PTSD symptoms, and postdeployment social support after deployment among 835 U.S. Army and 173 National Guard soldiers. Multiple regression analyses indicated that predeployment unit support was not significantly associated with postdeployment PTSD severity in either group of soldiers, whereas higher unit support during deployment was significantly associated with lower postdeployment PTSD severity among active duty soldiers only. Among both groups, higher levels of postdeployment social support were associated with lower levels of postdeployment PTSD symptom severity. These findings suggest that postdeployment social support is a particularly strong buffer against postdeployment PTSD symptoms among both groups of soldiers whereas the effects of unit support may be limited.

The mental health of the UK Armed Forces: where facts meet fiction

A substantial amount of research has been conducted into the mental health of the UK military in recent years. This article summarises the results of the various studies and offers possible explanations for differences in findings between the UK and other allied nations. Post-traumatic stress disorder (PTSD) rates are perhaps surprisingly low amongst British forces, with prevalence rates of around 4% in personnel who have deployed, rising to 6% in combat troops, despite the high tempo of operations in recent years. The rates in personnel currently on operations are consistently lower than these. Explanations for the lower PTSD prevalence in British troops include variations in combat exposures, demographic differences, higher leader to enlisted soldier ratios, shorter operational tour lengths and differences in access to long-term health care between countries. Delayed-onset PTSD was recently found to be more common than previously supposed, accounting for nearly half of all PTSD cases; however, many of these had sub-syndromal PTSD predating the onset of the full disorder. Rates of common mental health disorders in UK troops are similar or higher to those of the general population, and overall operational deployments are not associated with an increase in mental health problems in UK regular forces. However, there does appear to be a correlation between both deployment and increased alcohol misuse and post-deployment violence in combat troops. Unlike for regular forces, there is an overall association between deployment and mental health problems in Reservists. There have been growing concerns regarding mild traumatic brain injury, though this appears to be low in British troops with an overall prevalence of 4.4% in comparison with 15% in the US military. The current strategies for detection and treatment of mental health problems in British forces are also described. The stance of the UK military is that psychological welfare of troops is primarily a chain of command responsibility, aided by medical advice when necessary, and to this end uses third location decompression, stress briefings, and Trauma Risk Management approaches. Outpatient treatment is provided by Field Mental Health Teams and military Departments of Community Mental Health, whilst inpatient care is given in specific NHS hospitals.

Life in and after the Armed Forces: social networks and mental health in the UK military

This study focuses on the influence of structural aspects of social integration (social networks and social participation outside work) on mental health (common mental disorders (CMD), that is, depression and anxiety symptoms, post-traumatic stress disorder (PTSD) symptoms and alcohol misuse). This study examines differences in levels of social integration and associations between social integration and mental health among service leavers and personnel still in service. Data were collected from regular serving personnel (n=6,511) and regular service leavers (n=1,753), from a representative cohort study of the Armed Forces in the UK. We found that service leavers reported less social participation outside work and a general disengagement with military social contacts in comparison to serving personnel. Service leavers were more likely to report CMD and PTSD symptoms. The increased risk of CMD but not PTSD symptoms, was partially accounted for by the reduced levels of social integration among the service leavers. Maintaining social networks in which most members are still in the military is associated with alcohol misuse for both groups, but it is related to CMD and PTSD symptoms for service leavers only.

Support mechanisms and vulnerabilities in relation to PTSD in veterans of the Gulf War, Iraq War, and Afghanistan deployments: a systematic review

Pretrauma factors of psychiatric history and neuroticism have been important in highlighting vulnerability to posttraumatic stress disorder (PTSD), whereas posttrauma support mechanisms have been associated with positive health and well-being outcomes, particularly in veterans. The relationship between these factors and PTSD has not been the subject of a systematic review in veterans. An online search was conducted, supplemented by reference list and author searches. Two investigators systematically and independently examined eligible studies. From an initial search result of 2,864, 17 met inclusion criteria. A meta-analysis of unit cohesion involving 6 studies found that low unit cohesion was associated with PTSD, standardised mean difference of -1.62, 95% confidence interval (CI) [-2.80, -0.45]. A meta-analysis of social support involving 7 studies found that low social support was associated with PTSD, standardised mean difference of - 12.40, 95% CI [-3.42, -1.38]. Three of 5 studies found a significant relationship between low-family support and PTSD; insufficient data precluded a meta-analysis. Regarding pretrauma vulnerability, 2 studies on psychiatric history and 1 on neuroticism found positive relationships with PTSD. Posttrauma factors of low support were associated with higher reporting of PTSD. Cross-sectional methodology may be inadequate to capture complex relationships between support and PTSD; more longitudinal research is required.

Adverse health consequences of the Iraq War

The adverse health consequences of the Iraq War (2003-11) were profound. We conclude that at least 116,903 Iraqi non-combatants and more than 4800 coalition military personnel died over the 8-year course. Many Iraqi civilians were injured or became ill because of damage to the health-supporting infrastructure of the country, and about 5 million were displaced. More than 31,000 US military personnel were injured and a substantial percentage of those deployed suffered post-traumatic stress disorder, traumatic brain injury, and other neuropsychological disorders and their concomitant psychosocial problems. Many family members of military personnel had psychological problems. Further review of the adverse health consequences of this war could help to minimise the adverse health consequences of, and help to prevent, future wars.

The long-term consequences of military deployment: a 5-year cohort study of United kingdom reservists deployed to Iraq in 2003

Reserve and National Guard forces have been mobilized to an unprecedented degree in recent overseas conflicts. There is concern that rates of psychological problems may continue to rise for many years after deployment. The authors conducted a cohort study of 552 United Kingdom Reservists who deployed to Iraq in 2003 and 391 nondeployed Reservists. Measures of mental health and social functioning were collected a mean of 16 months and 4.8 years after return from possible deployment. At the first follow-up, deployment was associated with increased common mental disorder, post-traumatic stress disorder (PTSD), and poor general health. By the second follow-up, those who had deployed were no longer at increased risk for common mental disorder or poor general health and had good levels of social functioning. However, those who deployed continued to have over twice the odds of PTSD (odds ratio = 2.42, 95% confidence interval: 1.04, 5.62) and were more likely to report actual or serious consideration of separation from their partner. In conclusion, the authors found that the majority of mental health and social problems following deployment are transient. However, Reservists who deployed in the Iraq War remain at increased risk of PTSD and relationship problems 5 years after their tour of duty.

Longitudinal study of resilience and mental health in Marines leaving military service

BACKGROUND

Despite a growing emphasis on psychological outcomes following military combat, few longitudinal studies have examined the combined role of risk and protective factors in the mental health of combat-exposed military personnel. This study characterizes the impact of resilience scale scores and combat exposure on mental health outcomes among Marines after separating from military service, along with intra-individual changes in mental health status.

METHODS

Data were collected from longitudinal surveys of 475 active duty Marines attending a random sample of mandatory Transition Assistance Program workshops before leaving the military and responding to follow-up mail or web surveys an average of 6 months after returning to civilian life.

RESULTS

Results revealed distinct risk and protective factors for those meeting screening criteria for mental health problems (depression, anxiety, and PTSD) and functional impairment at follow-up. Primary risk factors included experiencing higher levels of pre-separation combat exposure; post-separation stress across multiple life domains; and experiencing multiple areas of pain post-separation. Protective factors include having higher scores on pre-separation resilience and perceived social support at follow-up indices. We also identified a number of factors associated with change in mental health status from baseline to follow-up.

LIMITATIONS

Generality is limited by a lower than expected follow-up response rate and an exclusively Marine sample.

CONCLUSION

The role of resilience appeared to have a greater impact on functional impairment than on mental health symptoms per se. Findings provide important input for enhancing training programs and services intended to promote adjustment from military to civilian life. Additional emphasis on social support and coping with stress-related issues are needed in support of combat veterans.