Do serving and ex-serving personnel of the UK armed forces seek help for perceived stress, emotional or mental health problems?

Sex and gender in psychotrauma research

Background: Posttraumatic stress disorder (PTSD) is two to three times more common in women than in men. To better understand this phenomenon, we need to know why men, women, and possibly individuals with other sex/gender identities respond differently to trauma. To stimulate sex and gender sensitive research, the European Journal of Psychotraumatology (EJPT) was the first journal to adopt a gender policy. In addition, a call for papers entitled Integrating and Evaluating Sex and Gender in Psychotrauma Research was announced.Objective: This special issue synthesizes the past five years of psychotrauma research with regard to sex/gender differences.Method: Seventy-seven articles were identified from EJPT archives, including five systematic reviews. These articles examined sex differences and/or gender differences in exposure to trauma, posttraumatic stress responses, or how sex and gender impacts (mental) health outcomes or treatment responses.Results: Findings from these studies outlined that: 1. sex and gender still need to be more clearly defined, also in relation to the context that codetermine trauma responses, like other 'diversity' variables; 2. in most studies, sex and gender are measured or reported as binary variables; 3. sex and gender are important variables when examining trauma exposure, responses to these events, symptoms trajectories, and mental and physical health outcomes across the life span; and 4. in PTSD treatment studies, including a meta-analysis and a systematic review, sex and gender were not significant predictors of treatment outcome.Conclusion: Future research must focus on sex and gender as important and distinct variables; they should include sex and gender in their statistical analyses plan to better clarify associations between these variables and (responses to) psychotrauma. To enhance reporting of comparable data across studies, we provide suggestions for future research, including how to assess sex and gender.

Level of perceived social support, and associated factors, in combat-exposed (ex-)military personnel: a systematic review and meta-analysis

PURPOSE

Combat deployment increases exposure to potentially traumatic events. Perceived social support (PSS) may promote health and recovery from combat trauma. This systematic review and meta-analysis aimed to synthesize studies investigating the level of PSS and associated factors among (ex-)military personnel who served in the Iraq/Afghanistan conflicts.

METHODS

Five electronic databases were searched in August 2023 and searches were restricted to the beginning of the Iraq/Afghanistan conflicts in 2001. The search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A quality assessment was carried out, and a meta-analysis and narrative synthesis were performed.

RESULTS

In total, 35 papers consisting of 19,073 participants were included. Of these, 31 studies were conducted in the United States (US) and 23 were cross-sectional. The pooled mean PSS score was 54.40 (95% CI: 51.78 to 57.01). Samples with probable post-traumatic stress disorder had a lower mean PSS score (44.40, 95% CI: 39.10 to 49.70). Approximately half of the included studies (n = 19) investigated mental health in relation to PSS, whilst only four explored physical health. The most frequently reported risk factors for low PSS included post-traumatic stress disorder, depression and anxiety, whilst post-traumatic growth and unit support were protective factors.

CONCLUSION

Higher levels of PSS were generally associated with more positive psychosocial and mental health-related outcomes following deployment. PSS should be targeted in psychosocial interventions and education programmes. Future research should investigate PSS in (ex-)military personnel across other countries and cultures, based on the lack of studies that focused on PSS in countries outside of the US.

Gender differences in structural and attitudinal barriers to mental healthcare in UK Armed Forces personnel and veterans with self-reported mental health problems

PURPOSE

Structural and attitudinal barriers often hinder treatment-seeking for mental health problems among members of the Armed Forces. However, little is known about potential gender differences in structural and attitudinal barriers among members of the UK Armed Forces. The current study aimed to explore how men and women differ in terms of these barriers to care among a sample of UK Armed Forces personnel and veterans with self-reported mental health problems.

METHODS

Currently serving and ex-serving members of the UK Armed Forces who self-reported a mental health problem were invited to participate in a semi-structured phone interview on mental health and treatment-seeking. The final sample included 1448 participants (1229 men and 219 women). All participants reported on their current mental health, public stigma, self-stigma, and barriers to mental healthcare.

RESULTS

Overall, men and women reported similar levels of both structural and attitudinal barriers, with no significant differences detected. The highest scores for both men and women were observed in attitudinal barriers relating to self-stigma domains, which encapsulate internalised attitudes and beliefs about mental illness and treatment.

CONCLUSIONS

Findings suggest that anti-stigma campaigns can be targeted simultaneously at both men and women within the Armed Forces. In particular, targeting self-stigma may be beneficial for health promotion campaigns.

Evaluation of Community Reinforcement and Family Therapy in the UK military community

Background: Partners and family can play a key role in encouraging military service and ex-service personnel to seek help for their mental health. Community Reinforcement Approach and Family Training (CRAFT) was developed to equip concerned significant others (CSOs) of those experiencing substance use disorders with skills to encourage their loved one to enter treatment and improve their own well-being. It was adapted in the US for CSOs of ex-service personnel with post-traumatic stress disorder (PTSD) (VA-CRAFT).Objective: This study aimed to evaluate an adaptation of VA-CRAFT for use with CSOs of serving and ex-service personnel experiencing PTSD and Common Mental Disorders in the UK (UKV-CRAFT).Method: Acceptability of UKV-CRAFT was assessed with interviews with experts, namely key stakeholders (n = 15) working in support provision for serving and ex-service personnel. In addition, individuals who took part in a small-scale demonstrative trial of UKV-CRAFT (three CSOs and three facilitators who delivered UKV-CRAFT) provided feedback.Results: UKV-CRAFT was viewed positively, with interviewees highlighting that programmes like UKV-CRAFT filled a gap in provision for UK Armed Forces families as most services were only available to the serving or ex-service personnel. Interviewees praised how UKV-CRAFT enhanced CSO well-being and communication with their loved one. Concerns over the confidentiality of taking part in UKV-CRAFT were raised due to the perceived negative effects of highlighting a loved one's mental ill health, especially for CSOs of serving personnel. Ideas for improvement included broadening access to all CSOs regardless of whether their loved one was seeking treatment.Conclusion: Interviewees regarded UKV-CRAFT as a potentially useful intervention suggesting it could be proactively offered universally to support timely help-seeking if required. We recommend further evaluation of UKV-CRAFT on a wider scale, incorporating our recommendations, to assess its effectiveness accurately.

Sustained positive behaviour change of wounded, injured and sick UK military following an adaptive adventure sports and health coaching recovery course

INTRODUCTION

A rising trend has occurred in the physical and mental health challenges faced by recovering UK service personnel. To support these individuals, bespoke inclusive multiactivity and adventurous training courses (MAC) have been developed. This study investigated the MAC's influence on participants' ability to sustain day-to-day changes that facilitate positive mental health and psychological need satisfaction.

METHODS

The 146 UK service personnel who participated in this study attended a five-day MAC 12 months ago. To investigate how the supportive experience influenced participants' lives, quantitative and qualitative data were collected via an online survey. Open-ended questioning and abductive analysis were conducted to understand mechanisms, influential aspects of the course and positive behaviour change.

RESULTS

Positive behaviour changes were reported by 74% of the respondents. These changes align with positive psychological well-being (98%). Impactful elements of the course experienced by participants mostly aligned with the three basic psychological needs of autonomy (34%), competence (36%) and relatedness (61%).

CONCLUSIONS

Recovery support programmes that encompass health coaching adventurous activities, such as the MAC, can initiate long-term positive behaviour change for recovering military personnel. In this specific context, the concurrence of the self-determination theory concepts that underpin the course delivery and participant outcomes is a powerful endorsement of implementation fidelity.

Prevalence of common mental health disorders in military veterans: using primary healthcare data

INTRODUCTION

Serving military personnel and military veterans have been identified as having a high prevalence of mental disorders. Since 1985, UK patients' primary healthcare (PHC) medical records contain Read Codes (now being replaced by Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT) codes) that mark characteristics such as diagnosis, ethnicity and therapeutic interventions. This English study accesses a cohort profile of British Armed Forces veterans to examine the diagnosed common mental disorders by using PHC records.

METHODS

This analysis has been drawn from initiatives with PHC practices in the Northwest of England to increase veteran registration in general practice. Demographic data were collected including gender, age and marital status. Data were also collected on common mental health disorders associated with the Armed Forces.

RESULT

2449 veteran PHC records were analysed. 38% (N=938) of veterans in this cohort had a code on their medical record for common mental health disorders. The highest disorder prevalence was depression (17.8%, N=437), followed by alcohol misuse (17.3%, N=423) and anxiety (15.0%, N=367). Lower disorder prevalence was seen across post-traumatic stress disorder (PTSD) (3.4%, N=83), dementia (1.8%, N=45) and substance misuse (0.8%, N=19). Female veterans had a higher prevalence of mental disorders than their male counterparts, while men a higher prevalence of PTSD; however, the gender difference in the latter was not significant (p>0.05).

CONCLUSION

The SNOMED searches do not detail why certain groups had higher recordings of certain disorders. A future study that accesses the PHC written medical notes would prove enlightening to specifically identify what situational factors are having the most impact on the veteran population. The results from a sizeable English veteran population provide information that should be considered in developing veteran-specific clinical provision, educational syllabus and policy.

Health and well-being of serving and ex-serving UK Armed Forces personnel: protocol for the fourth phase of a longitudinal cohort study

INTRODUCTION

This is the fourth phase of a longitudinal cohort study (2022-2023) to investigate the health and well-being of UK serving (Regulars and Reservists) and ex-serving personnel (veterans) who served during the era of the Iraq and Afghanistan conflicts. The cohort was established in 2003 and has collected data over three previous phases including Phase 1 (2004-2006), Phase 2 (2007-2009) and Phase 3 (2014-2016).

METHODS AND ANALYSIS

Participants are eligible to take part if they completed the King's Centre for Military Health Research Health and Wellbeing Cohort Study at Phase 3 (2014-2016) and consented to be recontacted (N=7608). Participants will be recruited through email, post and text message to complete an online or paper questionnaire. Data are being collected between January 2022 and September 2023. Health and well-being measures include measures used in previous phases that assess common mental disorders, post-traumatic stress disorder (PTSD) and alcohol misuse. Other areas of interest assess employment, help-seeking and family relationships. New topics include the impact of the British withdrawal from Afghanistan in 2021, complex PTSD (C-PTSD), illicit drug use, gambling and loneliness. Analyses will describe the effect size between groups deployed to Iraq and/or Afghanistan or not deployed, and those who are currently in service versus ex-service personnel, respectively, reporting prevalences with 95% CIs, and ORs with 95% CI. Multivariable logistic and multiple linear regression analyses will be conducted to assess various health and well-being outcomes and associations with risk and protective factors.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Ministry of Defence Research Ethics Committee (Ref: 2061/MODREC/21). Participants are provided with information and agree to a series of consent statements before taking part. Findings will be disseminated to UK Armed Forces stakeholders and international research institutions through stakeholder meetings, project reports and scientific publications.

Barriers and facilitators to mental healthcare for women veterans: a scoping review

BACKGROUND

Traditionally, veteran research and support have centred on the requirements of a predominantly male population. However, as female participation in the Armed Forces increases and their roles diversify, consideration of women's unique mental health needs is imperative. Women veterans are at greater risk of post-service mental health challenges than their male counterparts, and female mental health outcomes have deteriorated in recent years.

AIMS

To determine the provenance of these outcomes, a scoping review considering both barriers and facilitators to female veteran participation in mental health services was conducted.

METHODS

A review was carried out following the 2020 Joanna Briggs Institute Scoping Review framework. Twenty-four papers were identified, with all but one originating from the US.

RESULTS

This research indicated that whilst women experience barriers common to male veterans (e.g. help-seeking stigma), they also experience unique gender-specific barriers to accessing mental healthcare services (e.g. lack of gender-sensitive treatment options, feeling uncomfortable) and such barriers result in under-utilization of services.

CONCLUSIONS

Literature indicates that consideration and mitigation of these barriers might improve access and health outcomes for women veterans. Further research is required outside the US to understand the barriers to mental healthcare experienced by women veterans internationally.

Providing recovery support to wounded, injured, and sick UK military personnel throughout the COVID-19 pandemic

Health precautions implemented by the United Kingdom (UK) government to limit the spread of the Coronavirus Disease 2019 (COVID-19) led to the closure of many well-being support services in 2020. This created a need to re-think how impactful recovery support courses can be provided. One such service was that of the five-day Multi Activity Course (MAC) which was redesigned in accordance with national health guidelines to allow continued access for Wounded, Injured and Sick (WIS) military personnel to the service; the positive impacts of which are well established. This study investigated the influence of the newly developed Reduced numbers MAC (R-MAC) on the WIS participants lives during and for 12 months after attending. The R-MAC led to comparable impacts for participants well-being, at a time in which people's mental well-being was often being adversely affected. The positive mental well-being of the 261 participants improved by 33% throughout the course and remained 14% higher for the 37 participants who provided data six months after attending. Key facets of the experience that were most impactful for the participants were (i) shared experience with other veterans, (ii) discussing issues in a safe environment while receiving support from the staff and (iii) developing knowledge around self-help/personal development. Adapting to the challenging circumstances and developing the R-MAC mitigated against the already adverse impact of the COVID-19 pandemic for the WIS participants.

Evaluating a Smartphone App (MeT4VeT) to Support the Mental Health of UK Armed Forces Veterans: Feasibility Randomized Controlled Trial

BACKGROUND

Previous research demonstrates that less than 50% of military veterans experiencing mental health difficulties seek formal support. Veterans often struggle to identify problems as mental health difficulties. In addition, they may fail to recognize the need for support before reaching a crisis point and face difficulties navigating care pathways to access support.

OBJECTIVE

A feasibility trial was conducted to assess a novel digital smartphone app (Mental Health Toolkit for Veterans Project [MeT4VeT]) for UK Armed Forces (UKAF) veterans experiencing mental health difficulties. The trial aimed to explore the feasibility and acceptability of trial procedures for a later randomized controlled trial (RCT) and to assess the acceptability of the MeT4VeT app.

METHODS

Participants were recruited at UK military medical centers, by advertising on social media, and through veteran third-sector organizations between February and November 2021, and assessed for eligibility (male, owned a smartphone, served at least 2 years in the UKAF, left the UKAF within the last 2 years, not undertaking formal mental health treatment). Eligible participants were assigned, on a 1:1 ratio, to either the intervention group (full app) or a control group (noninteractive app with signposting information). Three key objectives were determined a priori to assess the practicality of running an RCT including an assessment of recruitment and retention, evaluation of the technical app delivery and measurement processes, and acceptability and usability of the intervention.

RESULTS

In total, 791 individuals completed the participant information sheet, of which 261 (33%) were ineligible, 377 (48%) declined or were unable to be contacted for consent, and 103 (13%) did not download the app or complete the baseline measures. Of this, 50 participants completed baseline measures and were randomly assigned to the intervention group (n=24) or the control group (n=26). The trial was effective at enabling both the technical delivery of the intervention and collection of outcome measures, with improvements in mental health demonstrated for the intervention group from baseline to the 3-month follow-up. Recruitment and retention challenges were highlighted with only 50 out of the 530 eligible participants enrolled in the trial. The acceptability and usability of the MeT4VeT app were generally supported, and it was reported to be a useful, accessible way for veterans to monitor and manage their mental health.

CONCLUSIONS

The results highlighted that further work is needed to refine recruitment processes and maintain engagement with the app. Following this, an RCT can be considered to robustly assess the ability of the app to positively affect mental health outcomes indicated within this trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05993676; https://clinicaltrials.gov/ct2/show/NCT05993676.

Heterogeneity in Unmet Treatment Need and Barriers to Accessing Mental Health Services Among U.S. Military Service Members with Serious Psychological Distress

The goal of the current study is to examine heterogeneity in mental health treatment utilization, perceived unmet treatment need, and barriers to accessing care among U.S. military members with probable need for treatment. Using data from the 2018 Department of Defense Health Related Behavior Survey, we examined a subsample of 2,336 respondents with serious psychological distress (SPD; past-year K6 score ≥ 13) and defined four mutually exclusive groups based on past-year mental health treatment (treated, untreated) and self-perceived unmet treatment need (recognized, unrecognized). We used chi-square tests and adjusted regression models to compare groups on sociodemographic factors, impairment (K6 score; lost work days), and endorsement of treatment barriers. Approximately 43% of respondents with SPD reported past-year treatment and no unmet need (Needs Met). The remainder (57%) met criteria for unmet need: 18% endorsed treatment and recognized unmet need (Treated/Additional Need); 7% reported no treatment and recognized unmet need (Untreated/Recognized Need); and 32% reported no treatment and no unmet need (Untreated/Unrecognized Need). Compared to other groups, those with Untreated/Unrecognized Need tended to be younger (ages 18-24; p = 0.0002) and never married (p = 0.003). The Treated/Additional Need and Untreated/Recognized Need groups showed similar patterns of treatment barrier endorsement, whereas the Untreated/Unrecognized Need group endorsed nearly all barriers at lower rates. Different strategies may be needed to increase appropriate mental health service use among different subgroups of service members with unmet treatment need, particularly those who may not self-perceive need for treatment.

Evaluation of the NHS England 'Op COURAGE' High Intensity Service for military veterans with significant mental health problems

INTRODUCTION

In November 2020, The NHS for England launched a pilot High Intensity Service (HIS) programme for treating military veterans complex mental health problems. Seven regional grants were awarded to manage the HIS, including NHS Solent, in South East England. This paper details an evaluation of the HIS, which was conducted from February 2021 to August 2022.

METHODS

This mixed-methods study gained quantitative data from a specifically designed questionnaire that included a number of validated psychometric questionnaires. These were completed by either HIS staff or beneficiaries at entry and exit from the HIS, and qualitative data were gained from semi-structured interviews with the HIS staff.

RESULTS

Data were sourced from 45 pre-questionnaires, 25 post programme questionnaires and 11 interviews. This evaluation identified reductions in situational stressors, symptoms and reported illnesses for veterans in crisis. There were reductions in depression, anxiety and post-traumatic stress disorder following programme exit. Staff reported that there was no notable changes in stress levels which appeared to remain high at programme exit. Staff interviews highlighted the importance of simultaneously understanding the social and psychological needs of veterans in mental health crisis. The benefits of integrating veteran staff members into military veteran health services were identified, demonstrating improvements in education around military culture in civilian services.

CONCLUSIONS

The importance of collaboration between clinical and veteran staff members in veteran health services was noted, demonstrating the positive impact social care provision has on veteran's overall health and well-being. Veteran engagement with the service was advocated as a result of veterans accessing the service feeling understood. This first independent evaluation of the HIS provides a positive reflection, and adds to the limited empirical evidence exploring veteran engagement in health services.

What do the Public Understand About Intimate Partner Violence in the Context of Military Veteran Status and PTSD?

Intimate Partner Violence (IPV) represents a significant public and social health concern and may present particular complexities in military veteran relationships which are subject to unique stressors including separations, transition to civilian life and increased risk of Post-Traumatic Stress Disorder (PTSD). Public understanding is vital in terms of ensuring access to services and appropriate intervention. However, little is known about the public perception of IPV in this context. This study sought to assess how public recognition and discourse is affected by military veteran status and a diagnosis of PTSD. Community participants (N = 269) were randomly allocated to one of four conditions and presented with a story containing IPV in which the profession (military veteran/civilian worker) and diagnostic status (PTSD/No PTSD) were manipulated. All participants rated the extent to which they felt the story contained IPV; additionally, half (n = 123) took part in a story completion task designed to elicit qualitative data with regards to public discourse. The mean scores in all conditions were weighted towards IPV recognition. Results indicated a small interaction between job role and PTSD (F[1265] = 7.888, p < 0.01, partial n² = 0.029) meaning that the public are more likely to recognise IPV when it is perpetrated by a military veteran than a civilian with PTSD. Diagnostic status made no difference to recognising abuse perpetrated by a military veteran. However, the fit of the model was weak (r² = .040) meaning that the large majority of variance was due to factors not accounted for. Qualitative findings indicated that in a military population trauma may be assumed even where not indicated and the public appear less likely to consider current stressors or acknowledge that PTSD cannot justify abuse. Victims of IPV in military relationships may therefore be particularly vulnerable to discourses that prioritise the victim status of the perpetrator.

Identifying Military Service Status in Electronic Healthcare Records from Psychiatric Secondary Healthcare Services: A Validation Exercise Using the Military Service Identification Tool

Electronic healthcare records (EHRs) are a rich source of information with a range of uses in secondary research. In the United Kingdom, there is no pan-national or nationally accepted marker indicating veteran status across all healthcare services. This presents significant obstacles to determining the healthcare needs of veterans using EHRs. To address this issue, we developed the Military Service Identification Tool (MSIT), using an iterative two-staged approach. In the first stage, a Structured Query Language approach was developed to identify veterans using a keyword rule-based approach. This informed the second stage, which was the development of the MSIT using machine learning, which, when tested, obtained an accuracy of 0.97, a positive predictive value of 0.90, a sensitivity of 0.91, and a negative predictive value of 0.98. To further validate the performance of the MSIT, the present study sought to verify the accuracy of the EHRs that trained the MSIT models. To achieve this, we surveyed 902 patients of a local specialist mental healthcare service, with 146 (16.2%) being asked if they had or had not served in the Armed Forces. In total 112 (76.7%) reported that they had not served, and 34 (23.3%) reported that they had served in the Armed Forces (accuracy: 0.84, sensitivity: 0.82, specificity: 0.91). The MSIT has the potential to be used for identifying veterans in the UK from free-text clinical documents and future use should be explored.

A comparison of probable post-traumatic stress disorder and alcohol consumption among active female members of the UK Police Service and UK Armed Forces

BACKGROUND

The British Police Service and Armed Forces are male-dominated occupations, characterised by frequent trauma exposure and intensive demands. Female police employees and military personnel may have unique experiences and face additional strains to their male counterparts. This analysis compared the levels of post-traumatic stress disorder (PTSD), hazardous/harmful alcohol consumption, and comorbidity in female police employees and military personnel.

METHODS

Police data were obtained from the Airwave Health Monitoring Study (N = 14,145; 2007-2015) and military data from the Health and Wellbeing Cohort Study (N = 928; phase 2: 2007-2009 and phase 3: 2014-2016). Multinomial/logistic regressions analysed sample differences in probable PTSD, hazardous (14-35 units per week) and harmful (35 + units per week) alcohol consumption, and comorbid problems. We compared covariate adjustment and entropy balancing (reweighting method controlling for the same covariates) approaches.

RESULTS

There were no significant differences in probable PTSD (police: 3.74% vs military: 4.47%) or hazardous drinking (police: 19.20% vs military: 16.32%). Female military personnel showed significantly higher levels of harmful drinking (4.71%) than police employees (2.42%; Adjusted Odds Ratios [AOR] = 2.26, 95% Confidence Intervals [CIs] = 1.60-3.21), and comorbidity (1.87%) than police employees (1.00%, AOR = 2.07, 95% CI = 1.21-3.54). Entropy balancing and covariate-adjustments obtained the same results.

CONCLUSIONS

Comparable levels of probable PTSD were observed, which are slightly lower than estimates observed in the female general population. Future research should explore the reasons for this. However, female military personnel showed higher levels of harmful drinking than police employees, emphasising the need for alcohol interventions in military settings.

Personalised digital technology for mental health in the armed forces: the potential, the hype and the dangers

The COVID-19 pandemic has resulted in a digital technology revolution which included widespread use in remote healthcare settings, remote working and use of technology to support friends and family to stay in touch. The armed forces have also increased its use of digital technology, but not at the same rate, and it is important that they do not fall behind in the revolution. One area where digital technology could be helpful is the treatment and management of mental health conditions. In a civilian setting, digital technology adoption has been found to be acceptable and feasible yet there is little use in the armed forces. In this personal view, we explore the potential use of personalised digital technology for mental health, the hype surrounding it and the dangers.This paper forms part of the special issue of BMJ Military Health dedicated to personalised digital technology for mental health in the armed forces.

Enablers and barriers to military veterans seeking help for mental health and alcohol difficulties: A systematic review of the quantitative evidence

OBJECTIVE

Research exploring the enablers and barriers that exist for military veterans seeking to address their poor mental health has produced ambiguous results. To identify the enablers and barriers correctly, this study systematically reviews the literature, including research that included alcohol and had a clearly defined veteran population.

METHODS

Six databases were searched. Inclusion criteria specified that empirical studies related to veterans that had ceased military service and were seeking help for poor mental health and/or alcohol difficulties. Critical Appraisal Skills Programme and AXIS appraisal tools were used to assess quality and bias. A narrative synthesis approach was adopted for analysis. From 2044 studies screened, 12 were included featuring 5501 participants.

RESULTS

Forty-four enablers and barriers were identified, with thirty-two being statistically significant. Post-traumatic stress disorder had the greatest number of enabler/barrier endorsements to veterans seeking help. Depression, anxiety, experience and attitudes also acted as enablers/barriers. Most studies were of fair methodological quality. Limitations included that samples were skewed towards US army veterans. Little research exists concerning those that have ceased military service.

CONCLUSIONS

Veteran help-seeking is likely enabled by poor mental health symptomology and comorbidity, which suggests veterans reach a crisis point before they seek help. Further research on alcohol misuse and attitude formation is required. The field would also benefit from alternative study designs including qualitative studies with non-US participants.

Awareness of and willingness to access support among UK military personnel who reported a mental health difficulty

LAY SUMMARY

Being aware of and willing to access mental health services are important first steps in seeking help for a self-reported mental health, stress, or emotional problem. Evidence shows that UK military personnel, in particular ex-serving personnel, are not always aware of or willing to access sources of mental health support. This study explored which sources of mental health support UK military personnel were aware of and willing to use if they self-reported a mental health, stress, or emotional problem. It also explored the possible differences between serving and ex-serving military personnel. All UK military personnel were most aware of and willing to access formal medical services. However, among ex-serving personnel, there was a low awareness of and willingness to use ex-serving-specific support services, such as the Veterans and Reserves Mental Health Programme, National Health Services Veterans Service, and Veterans UK helpline. Future service delivery and policy should focus on improving the variety of sources of support that ex-serving personnel are aware of and willing to use.

The evolution of PTSD symptoms in serving and ex-serving personnel of the UK armed forces from 2004 to 16: A longitudinal examination

Whilst most military personnel do not develop Post-Traumatic Stress Disorder (PTSD), ex-serving personnel exhibit higher levels compared to those in the military. The heterogeneity of symptom development for serving and ex-serving personnel has not yet been compared in the UK Armed Forces (UK AF). Latent class growth modelling was employed to estimate the trajectories of PTSD symptoms from three waves of data from the PTSD Checklist (PCL-C) from a UK AF sample (N = 7357). Regression mixture models were conducted to investigate covariates of class membership. Five trajectory classes were identified. Most of the sample reported no-low symptoms (71.3%). Of those reporting probable PTSD during the 12 year-period, 4.6% showed improvements, 4.9% worsened, and 1.8% displayed chronic symptoms. A class with subthreshold elevated symptoms (17.3%) was also identified. Trajectories of serving and ex-serving personnel were not substantially different, but more ex-serving personnel were symptomatic and those with chronic symptoms worsened over time. Chronic disorder was associated with lower rank, experiencing violent combat, and proximity to wounding/death on deployment. Worsening symptoms were associated with childhood stress/violence, lower rank, not being in a relationship, inconsistent post-deployment social support, proximity to wounding/death, and voluntary, or medical discharge. The present study found most UKAF personnel did not report PTSD symptoms between 2004 and 16 but, among those experiencing probable PTSD, more participants reported deteriorating/persistent symptoms than who improved. PTSD-onset was related to adversities across childhood and deployment, and lack of social support. Findings underscore the importance of addressing the through-life contributors of PTSD in order to prevent ingrained disorder.

Problem drinking recognition among UK military personnel: prevalence and associations

PURPOSE

Despite the higher prevalence of problem drinking in the UK military compared to the general population, problem recognition appears to be low, and little is known about which groups are more likely to recognise a problem. This study examined prevalence of problem drinking recognition and its associations.

METHODS

We analysed data from 6400 regular serving and ex-serving personnel, collected in phase 3 (2014-2016) of the King's Centre for Military Health Research cohort study.

MEASUREMENTS

Participants provided sociodemographic, military, health and impairment, life experiences, problem drinking, and problem recognition information. Problem drinking was categorised as scores ≥ 16 in the AUDIT questionnaire. Associations with problem recognition were examined with weighted logistic regressions.

FINDINGS

Among personnel meeting criteria for problem drinking, 49% recognised the problem. Recognition was most strongly associated (ORs ≥ 2.50) with experiencing probable PTSD (AOR = 2.86, 95% CI = 1.64-5.07), social impairment due to physical or mental health problems (AOR = 2.69, 95% CI = 1.51-4.79), adverse life events (AOR = 2.84, 95% CI = 1.70-4.75), ever being arrested (AOR = 2.99, CI = 1.43-6.25) and reporting symptoms of alcohol dependence (AOR = 3.68, 95% CI = 2.33-5.82). To a lesser extent, recognition was also statistically significantly associated with experiencing psychosomatic symptoms, feeling less healthy, probable common mental health disorders, and increased scores on the AUDIT.

CONCLUSION

Half of UK military personnel experiencing problem drinking does not self-report their drinking behaviour as problematic. Greater problem drinking severity, poorer mental or physical health, and negative life experiences facilitate problem recognition.

Post-traumatic growth among UK military personnel deployed to Iraq or Afghanistan: data from phase 3 of a military cohort study

BACKGROUND

Post-traumatic growth (PTG) refers to beneficial psychological change following trauma.

AIMS

This study explores the sociodemographic, health and deployment-related factors associated with PTG in serving/ex-serving UK armed forces personnel deployed to military operations in Iraq or Afghanistan.

METHOD

Multinomial logistic regression analyses were applied to retrospective questionnaire data collected 2014-2016, stratified by gender. PTG scores were split into tertiles of no/very low PTG, low PTG and moderate/large PTG.

RESULTS

A total of 1447/4610 male personnel (30.8%) and 198/570 female personnel (34.8%) reported moderate/large PTG. Male personnel were more likely to report moderate/large PTG compared with no/very low PTG if they reported a greater belief of being in serious danger (relative risk ratio (RRR) 2.47, 95% CI 1.68-3.64), were a reservist (RRR 2.37, 95% CI 1.80-3.11), reported good/excellent general health (fair/poor general health: RRR 0.33, 95% CI 0.24-0.46), a greater number of combat experiences, less alcohol use, better mental health, were of lower rank or were younger. Female personnel were more likely to report moderate/large PTG if they were single (in a relationship: RRR 0.40, 95% CI 0.22-0.74), had left military service (RRR 2.34, 95% CI 1.31-4.17), reported better mental health (common mental disorder: RRR 0.37, 95% CI 0.17-0.84), were a reservist, reported a greater number of combat experiences or were younger. Post-traumatic stress disorder had a curvilinear relationship with PTG.

CONCLUSIONS

A moderate/large degree of PTG among the UK armed forces is associated with mostly positive health experiences, except for post-traumatic stress disorder.

Mental health outcomes of male UK military personnel deployed to Afghanistan and the role of combat injury: analysis of baseline data from the ADVANCE cohort study

BACKGROUND

The long-term psychosocial outcomes of UK armed forces personnel who sustained serious combat injuries during deployment to Afghanistan are largely unknown. We aimed to assess rates of probable post-traumatic stress disorder (PTSD), depression, anxiety, and mental health-associated multimorbidity in a representative sample of serving and ex-serving UK military personnel with combat injuries, compared with rates in a matched sample of uninjured personnel.

METHODS

This analysis used baseline data from the ADVANCE cohort study, in which injured individuals were recruited from a sample of UK armed forces personnel who were deployed to Afghanistan and had physical combat injuries, according to records provided by the UK Ministry of Defence. Participants from the uninjured group were frequency-matched by age, rank, regiment, deployment, and role on deployment. Participants were recruited through postal, email, and telephone invitations. Participants completed a comprehensive health assessment, including physical health assessment and self-reported mental health measures (PTSD Checklist, Patient Health Questionnaire-9, and Generalised Anxiety Disorder-7). The mental health outcomes were rates of PTSD, depression, anxiety, and mental health-associated multimorbidity in the injured and uninjured groups. The ADVANCE study is ongoing and is registered with the ISRCTN registry, ISRCTN57285353.

FINDINGS

579 combat-injured participants (161 with amputation injuries and 418 with non-amputation injuries) and 565 uninjured participants were included in the analysis. Participants had a median age of 33 years (IQR 30-37 years) at the time of assessment. 90·3% identified as White and 9·7% were from all other ethnic groups. The rates of PTSD (16·9% [n=89] vs 10·5% [n=53]; adjusted odds ratio [AOR] 1·67 [95% CI 1·16-2·41], depression (23·6% [n=129] vs 16·8% [n=87]; AOR 1·46 [1·08-2·03]), anxiety (20·8% [n=111] vs 13·5% [n=71]; AOR 1·56 [1·13-2·24]) and mental health-associated multimorbidity (15·3% [n=81] vs 9·8% [n=49]; AOR 1·62 [1·12-2·49]) were greater in the injured group than the uninjured group. Minimal differences in odds of reporting any poor mental health outcome were noted between the amputation injury subgroup and the uninjured group (AOR range 0·77-0·97), whereas up to double the odds were noted for the non-amputation injury subgroup compared with the uninjured group (AOR range 1·74-2·02).

INTERPRETATION

Serious physical combat injuries were associated with poor mental health outcomes. However, the type of injury sustained influenced this relationship. Regardless of injury, this cohort represents a group who present with greater rates of PTSD than the general population, as well as increased psychological burden from multimorbidity.

FUNDING

The ADVANCE Charity.

Gambling problems and associated harms in United Kingdom Royal Air Force personnel

International evidence indicates that currently serving and former military personnel may be at heightened vulnerability to problem gambling. The aim of the present study was to undertake the first survey of gambling experience and potential problems among serving United Kingdom Royal Air Force (RAF) personnel. Our objectives were to survey the frequency of gambling problems, types of gambling activities, examine mental health, alcohol use, and COVID-19-related associations with gambling, and identify potential risk factors for problem gambling among RAF personnel. A cross-sectional online survey was distributed to all serving RAF personnel in January 2021 and the final dataset consisted of n = 2119 responses. The Problem Gambling Severity Index (PGSI) identified gambling severity, the Patient Health Questionnaire (PHQ-9) assessed depression, the Generalized Anxiety Disorder assessment (GAD-7) measured anxiety, and alcohol use was assessed with the Alcohol Use Disorders Identification Test (AUDIT). Questions relating to COVID-19 asked whether the pandemic had impacted one's gambling, mental health, and alcohol use. Findings indicated that 12.5% of personnel reported gambling problems, which included 8.0% with PGSI scores indicating low-risk gambling (1-2), 2.9% with moderate-risk gambling scores (3-4), and 1.6% with scores indicating problem gambling (≥8). Most personnel had no symptoms of depression or anxiety, and most experienced lower risk drinking levels. The likelihood of any gambling problem (PGSI ≥ 1) in RAF personnel was associated with age (18-24 years old), male gender, and Non-Commissioned ranks. Most participants reported a deterioration in their mental health due to COVID-19 and increased risky gambling. These findings indicate that gambling problems and associated harms are significant concerns for serving RAF personnel.

Exploring the impact of COVID-19 and restrictions to daily living as a result of social distancing within veterans with pre-existing mental health difficulties

INTRODUCTION

Data are emerging showing the adverse consequences on mental health of the general public due to the COVID-19 pandemic. Little is known about the needs of veterans with pre-existing mental health difficulties during the COVID-19 pandemic.

METHODS

Data were collected through a cross-sectional online survey from a randomly selected sample (n=1092) of military veterans who have sought help for mental health difficulties from a veteran-specific UK-based charity. The response rate was 25.2% (n=275). Participants were asked to complete a range of standardised mental health outcomes (post-traumatic stress disorder (PTSD): Post-traumatic Stress Disorder Checklist, common mental health difficulties (CMDs): 12-Item General Health Questionnaire, difficulties with anger: 5-Item Dimensions of Anger Reactions-Revised and alcohol misuse: Alcohol Use Disorders Identification Test) and endorse a list of potential stressors related to changes to daily life resulting from COVID-19. Regression analyses were fitted to explore predictors of mental health severity.

RESULTS

It was observed that symptoms of common mental disorder and PTSD (69.3% and 65.0%, respectively) were the most commonly reported to have been exacerbated by the pandemic. Lack of social support and reporting increasing numbers of stressors related to COVID-19 were consistently associated with increasing severity of a range of mental health difficulties.

CONCLUSIONS

Our findings suggest veterans who had pre-existing mental health difficulties prior to the outbreak of COVID-19 may be at increased risk of experiencing CMDs as a result of the pandemic. Intervening to improve levels of social support and offering practical guidance to better manage any additional stressors relating to the pandemic may provide strategies to help reduce the burden of mental health symptoms.

Pathways to mental health care in active military populations across the Five-Eyes nations: An integrated perspective

Military service is associated with increased risk of mental health problems. Previous reviews have pointed to under-utilization of mental health services in military populations. Building on the most recent systematic review, our narrative, critical review takes a complementary approach and considers research across the Five-Eyes nations from the past six years to update and broaden the discussion on pathways to mental healthcare in military populations. We find that at a broad population level, there is improvement in several indicators of mental health care access, with greater gains in initial engagement, time to first treatment contact, and subjective satisfaction with care, and smaller gains in objective indicators of adequacy of care. Among individual-level barriers to care-seeking, there is progress in improving recognition of need for care and reducing stigma concerns. Among organizational-level barriers, there are advances in availability of services and cultural acceptance of care-seeking. Other barriers, such as concerns around confidentiality, career impact, and deployability persist, however, and may account for some remaining unmet need. To address these barriers, new initiatives that are more evidence-based, theoretically-driven, and culturally-sensitive, are therefore needed, and must be rigorously evaluated to ensure they bring about additional improvements in pathways to care.

Mental well-being interventions in the military: The ten key principles

Organisations including the United Kingdom Armed Forces should seek to implement mental health interventions to increase the psychological well-being of their workforce. This editorial briefly presents ten key principles that military forces should consider before implementing such interventions. These include job-focused training; evaluating interventions; the use of internal versus external training providers; the role of leaders; unit cohesion, single versus multiple session psychological interventions; not overgeneralising the applicability of interventions; the need for repeated skills practice; raising awareness and the fallibility of screening.

Burnout in Spanish Security Forces during the COVID-19 Pandemic

Since the beginning of the COVID-19 pandemic in Spain, members of the State Security Forces and the Armed Forces have been mobilized to guarantee the security and mobility of the population and to support health institutions by providing personnel for care, creating field hospitals, transferring the sick and the dead, etc. The objective of this study was to determine the levels of burnout in these professionals using the Maslach Burnout Inventory (MBI) scale, both in its different subscales and its total value. The study was developed using a quantitative methodology through a simple random sample (n = 2182). An ad hoc questionnaire was administered including variables related to: (a) socio-demographic issues, (b) subjective perceptions about their working conditions and the need for psychological and psychiatric treatment, and (c) the Death Anxiety Scale developed by Collett-Lester, and the MBI. The results show high levels of burnout (28.5%) in all its subscales: emotional exhaustion (53.8%), depersonalization (58.0%), and lack of personal development (46.3%). The logistic regression verifies a series of predictive variables that coincide in each of the subscales. These data indicate the need to implement prevention and treatment measures for workers so that their, stress, and anxiety to which they are subjected during their professional activity does not become a norm that can have negative repercussions for them, especially given the risk of new pandemic waves.

Barriers and facilitators for treatment-seeking for mental health conditions and substance misuse: multi-perspective focus group study within the military

BACKGROUND

Globally, millions are exposed to stressors at work that increase their vulnerability to develop mental health conditions and substance misuse (such as soldiers, policemen, doctors). However, these types of professionals especially are expected to be strong and healthy, and this contrast may worsen their treatment gap. Although the treatment gap in the military has been studied before, perspectives of different stakeholders involved have largely been ignored, even though they play an important role.

AIMS

To study the barriers and facilitators for treatment-seeking in the military, from three different perspectives.

METHOD

In total, 46 people participated, divided into eight homogeneous focus groups, including three perspectives: soldiers with mental health conditions and substance misuse (n = 20), soldiers without mental health conditions and substance misuse (n = 10) and mental health professionals (n = 16). Sessions were audio-taped and transcribed verbatim. Content analysis was done by applying a general inductive approach using ATLAS.ti-8.4.4 software.

RESULTS

Five barriers for treatment-seeking were identified: fear of negative career consequences, fear of social rejection, confidentiality concerns, the 'strong worker' workplace culture and practical barriers. Three facilitators were identified: social support, accessibility and knowledge, and healthcare within the military. The views of the different stakeholder groups were highly congruent.

CONCLUSIONS

Barriers for treatment-seeking were mostly stigma related (fear of career consequences, fear of social rejection and the 'strong worker' workplace culture) and this was widely recognised by all groups. Social support from family, peers, supervisors and professionals were identified as important facilitators. A decrease in the treatment gap for mental health conditions and substance misuse is needed and these findings provide direction for future research and destigmatising interventions.

Drinking motivations in UK serving and ex-serving military personnel

BACKGROUND

Drinking motivations within the UK military have not been studied despite the high prevalence of alcohol misuse in this group.

AIMS

We aimed to characterize drinking motivations and their demographic, military and mental health associations in UK serving and ex-serving personnel.

METHODS

Serving and ex-serving personnel reporting mental health, stress or emotional problems occurring in the last 3 years were selected from an existing cohort study. A semi-structured telephone interview survey examined participants' mental health, help-seeking, alcohol use and drinking motivations.

RESULTS

Exploratory factor analysis of drinking motivations in military personnel (n = 1279; response rate = 84.6%) yielded 2 factors, labelled 'drinking to cope' and 'social pressure'. Higher drinking to cope motivations were associated with probable anxiety (rate ratio [RR] = 1.4; 95% confidence interval [CI] = 1.3-1.5), depression (RR = 1.3; 95% CI = 1.2-1.4) and post-traumatic stress disorder (RR = 1.4; 95% CI = 1.3-1.6). Higher social pressure motivations were associated with probable anxiety (odds ratio = 1.1; 95% CI = 1.0-1.1). Alcohol misuse and binge drinking were associated with reporting higher drinking to cope motivations, drinking at home and drinking alone.

CONCLUSIONS

Amongst military personnel with a stress, emotional or mental health problem, those who drink to cope with mental disorder symptoms or because of social pressure, in addition to those who drink at home or drink alone, are more likely to also drink excessively.

Evaluating the Efficacy of a Mobile App (Drinks:Ration) and Personalized Text and Push Messaging to Reduce Alcohol Consumption in a Veteran Population: Protocol for a Randomized Controlled Trial

Background

Alcohol misuse is higher in the UK Armed Forces than in the general population. Previous research has shown that interventions delivered via smartphones are efficacious in promoting self-monitoring of alcohol use, have utility in reducing alcohol consumption, and have a broad reach.

Objective

This single-blinded randomized controlled trial (RCT) aims to assess the efficacy of a 28-day brief alcohol intervention delivered via a smartphone app (Drinks:Ration) in reducing weekly self-reported alcohol consumption between baseline and 3-month follow-up among veterans who drink at a hazardous or harmful level and receive or have received support for mental health symptoms in a clinical setting.

Methods

In this two-arm, single-blinded RCT, a smartphone app that includes interactive features designed to enhance participants’ motivation and personalized messaging is compared with a smartphone app that provides only government guidance on alcohol consumption. The trial will be conducted in a veteran population that has sought help through Combat Stress, a UK veteran’s mental health charity. Recruitment, consent, and data collection will be carried out automatically through the Drinks:Ration platform. The primary outcome is the change in self-reported weekly alcohol consumption between baseline (day 0) and 3-month follow-up (day 84) as measured using the Time-Line Follow back for Alcohol Consumption. Secondary outcome measures include (1) change in the baseline to 3-month follow-up (day 84) Alcohol Use Disorder Identification Test score and (2) change in the baseline to 3-month follow-up (day 84) World Health Organization Quality of Life-BREF score to assess the quality of adjusted life years. Process evaluation measures include (1) app use and (2) usability ratings as measured by the mHealth App Usability Questionnaire. The primary and secondary outcomes will also be reassessed at the 6-month follow-up (day 168) to assess the longer-term benefits of the intervention, which will be reported as a secondary outcome.

Results

The study will begin recruitment in October 2020 and is expected to require 12 months to complete. The study results will be published in 2022.

Conclusions

This study assesses whether a smartphone app is efficacious in reducing self-reported alcohol consumption in a veteran population that has sought help through Combat Stress using personalized messaging and interactive features. This innovative approach, if successful, may provide a means to deliver a low-cost health promotion program that has the potential to reach large groups, in particular those who are geographically dispersed, such as military personnel.

Trial Registration

ClinicalTrials.gov NCT04494594; https://clinicaltrials.gov/ct2/show/NCT04494594

International Registered Report Identifier (IRRID)

PRR1-10.2196/19720

Managing mental health on a prolonged deployment: UK military exercise SAIF SAREEA 3

INTRODUCTION

This paper presents the burden of mental health cases throughout UK military exercise SAIF SAREEA 3 (SS3), a low-tempo armoured brigade exercise in Oman from June to November 2018, and aims to discuss ways that mental health may be better managed on future large exercises.

METHODS

A retrospective review of all attendances at army medical facilities and relevant computerised medical records was undertaken.

RESULTS

14 mental health cases were identified, which required 51 follow-up presentations throughout the duration of SS3. This represented 1.2% of all first patient presentations, and 6.3% of all follow-up work. 64% had diagnoses which predated deployment and could all be classified within 10th revision of International Statistical Classification of Diseases and Related Health Problems as either F30-F39 mood (affective) disorders, or F40-F48 neurotic, stress-related and somatoform disorders; all new diagnoses made while deployed were adjustment disorders. The medical officer spent an average of 147 min total clinical care time per patient. Six patients were aeromedically evacuated (AE), which represented 26% of all AE cases from SS3.

CONCLUSIONS

Presentations were low, but time consuming and with poor disposal outcomes. Most conditions predated the exercise, and could have been predicted to worsen through the deployment. Given the disproportionate burden that mental health cases afforded during SS3, future brigade-sized deployments should include deployed mental health professionals in order to offer evidence-based therapy which should lead to improved disposal outcomes and a reduced AE burden.

The Development of the Military Service Identification Tool: Identifying Military Veterans in a Clinical Research Database Using Natural Language Processing and Machine Learning

BACKGROUND

Electronic health care records (EHRs) are a rich source of health-related information, with potential for secondary research use. In the United Kingdom, there is no national marker for identifying those who have previously served in the Armed Forces, making analysis of the health and well-being of veterans using EHRs difficult.

OBJECTIVE

This study aimed to develop a tool to identify veterans from free-text clinical documents recorded in a psychiatric EHR database.

METHODS

Veterans were manually identified using the South London and Maudsley (SLaM) Biomedical Research Centre Clinical Record Interactive Search-a database holding secondary mental health care electronic records for the SLaM National Health Service Foundation Trust. An iterative approach was taken; first, a structured query language (SQL) method was developed, which was then refined using natural language processing and machine learning to create the Military Service Identification Tool (MSIT) to identify if a patient was a civilian or veteran. Performance, defined as correct classification of veterans compared with incorrect classification, was measured using positive predictive value, negative predictive value, sensitivity, F1 score, and accuracy (otherwise termed Youden Index).

RESULTS

A gold standard dataset of 6672 free-text clinical documents was manually annotated by human coders. Of these documents, 66.00% (4470/6672) were then used to train the SQL and MSIT approaches and 34.00% (2202/6672) were used for testing the approaches. To develop the MSIT, an iterative 2-stage approach was undertaken. In the first stage, an SQL method was developed to identify veterans using a keyword rule-based approach. This approach obtained an accuracy of 0.93 in correctly predicting civilians and veterans, a positive predictive value of 0.81, a sensitivity of 0.75, and a negative predictive value of 0.95. This method informed the second stage, which was the development of the MSIT using machine learning, which, when tested, obtained an accuracy of 0.97, a positive predictive value of 0.90, a sensitivity of 0.91, and a negative predictive value of 0.98.

CONCLUSIONS

The MSIT has the potential to be used in identifying veterans in the United Kingdom from free-text clinical documents, providing new and unique insights into the health and well-being of this population and their use of mental health care services.

Predictors of not working among treatment-seeking UK veterans: a cross-sectional study

INTRODUCTION

Many veterans do well reintegrating to civilian life following military service. Yet, many face difficulties in finding and securing work. Veterans are more likely than civilians to experience work difficulties, but there remains little research investigating contributing factors, particularly among samples of treatment-seeking veterans. As such, the study examines predictors of not working among UK treatment-seeking veterans.

DESIGN

The study employed a cross-sectional design.

METHODS

Of 667 treatment-seeking UK veterans, 403 (M_age =50.94) provided information on a range of demographic variables, military-related experiences, the total number of physical health conditions and mental health outcomes. Work status was categorised as not working due to illness (M_age =48.15), not working due to other reasons (M_age =61.92) and currently working (M_age = 46.13).

RESULTS

Prevalence rates of not working was 69%. Not working was predicted by a greater number of physical health problems as well as more years since leaving the military. Not working due to poor health was independently predicted by symptoms of post-traumatic stress disorder (PTSD) and younger age, while not working due to other reasons was predicted by older age.

CONCLUSIONS

The study revealed that treatment-seeking veterans of younger age with a high number of physical health difficulties, symptoms of PTSD and more years since leaving the military are most at risk of not working due to ill health. The findings have important implications for identifying veterans most at risk of not working and offer the opportunity to tailor rehabilitation programmes to promote successful veteran reintegration into civilian life.

Sources of occupational stress among the military musicians of the Royal Air Force

INTRODUCTION

Occupational stress has been studied in the military and among professional musicians but not yet among military musicians. We may speculate that military musicians are subject to military occupational stresses as well as those of the professional musician, but we do not know what the stresses of the role actually are. This study is the first to identify sources of occupational stress and measure the prevalence of music performance anxiety (MPA) among a group of military musicians.

METHODS

Volunteer musicians were recruited from the UK Royal Air Force (RAF) Music Services and invited to take part in an anonymous online survey that captured demographic information, incorporated the Kenny Music Performance Anxiety Inventory (K-MPAI) and asked an open, free-text question: 'Thinking about your occupation as an RAF Musician, what causes you to feel stressed?'. Quantitative data were analysed using SPSS. Qualitative data were coded, collated and analysed for themes.

RESULTS

57 musicians (38% of those eligible) completed the survey. A prevalence of 46% for significant MPA was found. Females scored significantly higher than males. Other stressors were time constraints, the negative judgement of others, musical and military challenges, tensions between musical and military values, issues relating to promotion and existential concerns.

CONCLUSIONS

Military musicians share MPA, career development stressors and conflicts between career and social life as sources of occupational stress with their civilian colleagues. Military stressors include being posted/deployed or compulsory fitness testing. The hierarchical structure of the military brings additional stress when rank and promotion may not be talent based.

A validation study of the International Trauma Questionnaire to assess post-traumatic stress disorder in treatment-seeking veterans

BACKGROUND

Veterans with post-traumatic stress disorder (PTSD) typically report a poorer treatment response than those who have not served in the Armed Forces. A possible explanation is that veterans often present with complex symptoms of PTSD. ICD-11 PTSD and complex PTSD (CPTSD) have not previously been explored in a military sample.

AIMS

This study aimed to validate the only measure of ICD-11 PTSD and CPTSD, the International Trauma Questionnaire, and assess the rates of the disorder in a sample of treatment-seeking UK veterans.

METHOD

A sample of help-seeking veterans (N = 177) was recruited from a national charity in the UK that provides clinical services to veterans. Participants completed measures of ICD-11 PTSD and CPTSD as well as childhood and adult traumatic life events. Confirmatory factor analysis was used to assess the latent structure of PTSD and CPTSD symptoms, and rates of the disorders were estimated.

RESULTS

The majority of the participants (70.7%) reported symptoms consistent with a diagnosis of either PTSD or CPTSD. Results indicated the presence of two separate disorders, with CPTSD being more frequently endorsed (56.7%) than PTSD (14.0%). CPTSD was more strongly associated with childhood trauma than PTSD.

CONCLUSIONS

The International Trauma Questionnaire can adequately distinguish between PTSD and CPTSD within clinical samples of veterans. There is a need to explore the effectiveness of existing and new treatments for CPTSD in military personnel.

The journey to professional mental health support: a qualitative exploration of the barriers and facilitators impacting military veterans' engagement with mental health treatment

Background: It is often claimed that military veterans are reticent to seek help for mental disorders, even though delayed treatment may impair recovery and impact the wellbeing of those close to the veteran. Objective: This paper aims to explore the barriers and facilitators to accessing professional mental health support for three groups of veterans who met criteria for a probable mental health disorder and: (1) do not recognize a probable mental disorder; (2) recognize they are affected by a mental disorder but are not seeking professional support; or (3) are currently seeking professional mental health support. Method: Qualitative telephone interviews were conducted with 62 UK military veterans. Thematic analysis identified core themes along an illustrative journey towards professional mental health support. Results: Distinct barriers and facilitators to care were discussed by each group of veterans depicting changes as veterans moved towards accessing professional mental health support. In contrast to much of the literature, stigma was not a commonly reported barrier to care; instead care-seeking decisions centred on a perceived need for treatment, waiting until a crisis event occurred. Whilst the recognition of treatment need represented a pivotal moment, our data identified numerous key steps which had to be surmounted prior to care-seeking. Conclusion: As care-seeking decisions within this sample appeared to centre on a perceived need for treatment future efforts designed to encourage help-seeking in UK military veterans may be best spent targeting the early identification and management of mental health disorders to encourage veterans to seek support before reaching a crisis event.

Fear N. Identifying Veterans Using Electronic Health Records in the United Kingdom: A Feasibility Study

There is a lack of quantitative evidence concerning UK (United Kingdom) Armed Forces (AF) veterans who access secondary mental health care services-specialist care often delivered in high intensity therapeutic clinics or hospitals-for their mental health difficulties. The current study aimed to investigate the utility and feasibility of identifying veterans accessing secondary mental health care services using National Health Service (NHS) electronic health records (EHRs) in the UK. Veterans were manually identified using the Clinical Record Interactive Search (CRIS) system-a database holding secondary mental health care EHRs for an NHS Trust in the UK. We systematically and manually searched CRIS for veterans, by applying a military-related key word search strategy to the free-text clinical notes completed by clinicians. Relevant data on veterans' socio-demographic characteristics, mental disorder diagnoses and treatment pathways through care were extracted for analysis. This study showed that it is feasible, although time consuming, to identify veterans through CRIS. Using the military-related key word search strategy identified 1600 potential veteran records. Following manual review, 693 (43.3%) of these records were verified as "probable" veterans and used for analysis. They had a median age of 74 years (interquartile range (IQR): 53-86); the majority were male (90.8%) and lived alone (38.0%). The most common mental diagnoses overall were depressive disorders (22.9%), followed by alcohol use disorders (10.5%). Differences in care pathways were observed between pre and post national service (NS) era veterans. This feasibility study represents a first step in showing that it is possible to identify veterans through free-text clinical notes. It is also the first to compare veterans from pre and post NS era.

Suicidal Ideation, Suicidal Attempts, and Self-Harm in the UK Armed Forces

INTRODUCTION

In the UK military, suicide is infrequent and studies of self-harm behavior in this population are rare.

OBJECTIVES

To compare lifetime self-harm rates estimated on three occasions between 2004 and 2016 and to explore the associates of lifetime self-harm.

METHOD

Three phases of a UK AF cohort study (n = 10,272, 9,990, and 8,581, respectively) provided data. Telephone interviews assessed associates of self-harm among cohort members who reported subjective mental health problems in the past 3 years (n = 1,448). Validated measures of mental health and related stigmatization, social support, and help-seeking were obtained.

RESULTS

Lifetime self-harm increased significantly (p < .001) from 1.8% among serving personnel and 3.8% among veterans in 2004/06 to 1.9% and 4.5% in 2007/09 and to 4.2% and 6.6% in 2014/16 in the two groups, respectively. Veterans were consistently significantly more likely to report lifetime self-harm than serving personnel. Significant determinants of lifetime self-harm included current mental disorder symptoms, stigmatization, poor social support, suicidal ideation, and seeking help from formal medical sources.

CONCLUSION

Self-harm has increased over time in the UK serving and veteran community. Suicide prevention should focus on ameliorating mental disorder by encouraging engagement with health care, reducing negative views of mental illness, and fostering social support.

Perceived stigma and barriers to care in UK Armed Forces personnel and veterans with and without probable mental disorders

Background

Previous studies have found that perceptions of mental health related stigma can negatively impact help-seeking, particularly in military samples. Moreover, perceptions of stigma and barriers to care can vary between individuals with different psychiatric disorders. The aim of this study was to examine whether perceptions of stigma and barriers to care differed in a UK military sample between those with and without a current likely mental health diagnosis.

Method

Structured telephone interviews were carried out with 1432 service personnel and veterans who reported recent subjective mental ill health in the last 3 years. Participants completed self-reported measures relating to perceived stigma, barriers to care and psychological wellbeing.

Results

Those meeting criteria for probable common mental disorders (CMD) and PTSD were significantly more likely to report concerns relating to perceived and internalised stigma and barriers to care compared to participants without a likely mental disorder. Compared to individuals with likely CMD and alcohol misuse, those with probable PTSD reported higher levels of stigma-related concerns and barriers to care – although this difference was not significantly different.

Conclusions

These results indicate that perceptions of stigma continue to exist in UK serving personnel and military veterans with current probable mental disorders. Efforts to address particular concerns (e.g. being seen as weak; difficulty accessing appointments) may be worthwhile and, ultimately, lead to improvements in military personnel and veteran wellbeing.

Evaluating an Internet-based video cognitive processing therapy intervention for veterans with PTSD: A pilot study

INTRODUCTION

There remain a number of UK military veterans who are not able to access psychological therapies for post-traumatic stress disorder (PTSD). Some of these barriers are practical, including the need to balance work and other life commitments with attendance at residential or outpatient appointments. There is a need to investigate more accessible and flexible methods of delivering psychological therapies to veterans. One such alternative is to use remote-access video technology, often referred to as tele-therapy. The aims of the present study were to explore the feasibility of using tele-therapy in this population, whilst also reporting mental health outcomes for those who accessed the intervention.

METHODS

Participants were recruited from a UK veterans mental health charity. The intervention consisted of 12 sessions of cognitive processing therapy delivered via Skype. Participants completed various measures of mental health, including PTSD at three time points: pre-treatment, post-treatment and at three months follow-up. A measure of therapeutic alliance was also completed by participants and the clinician.

RESULTS

A total of 27 participants engaged in tele-therapy, with a treatment completion rate of 79% and a 'did not attend' rate of 12%, which compared well against similar outpatient services. All mental health outcomes showed maintained improvement at three months follow-up, with the highest effect size recorded for PTSD. Therapeutic alliance was also rated highly by both participants and the clinician.

DISCUSSION

The findings suggest that tele-therapy could provide a viable alternative format for delivering trauma-focused psychological therapies to veterans. Limitations and recommendations for future research are also presented.

A Qualitative Evaluation of the Acceptability of a Tailored Smartphone Alcohol Intervention for a Military Population: Information About Drinking for Ex-Serving Personnel (InDEx) App

Background

Alcohol consumption in the UK Armed Forces is higher than in the general population, and this pattern continues after leaving the service. Smartphone apps may be useful to increase ex-serving personnel’s awareness of their alcohol consumption, support self-monitoring, and prompt a change in behavior.

Objective

The study aimed to explore the acceptability of Information about Drinking in Ex-serving personnel (InDEx), a tailored smartphone app, combined with personalized short message service (SMS) text messaging designed to target ex-serving personnel who meet the criteria for hazardous alcohol use.

Methods

The InDEx intervention included 4 key modules: (1) assessment and normative feedback, (2) self-monitoring and feedback, (3) goal setting and review, and (4) personalized SMS text messaging. A semistructured telephone interview study was conducted with ex-serving personnel after using the app for a 28-day period. Interviews were used to explore the acceptability of app modules and its functionality and the perceived changes in participant’s drinking. Interview transcripts were analyzed using inductive thematic analysis.

Results

Overall, 94% (29/31) participants who used InDEx agreed to take part in a telephone interview. Overall, 4 themes were identified: Credibility, Meeting their needs, Simplicity, and Helpful for ex-serving personnel. The importance of credibility, functionality, and meeting the individual needs of ex-serving personnel was emphasized. Acceptability and engagement with specific modules of the app and text messages were influenced by the following: (1) if they felt it provided credible information, (2) whether the content was appropriately personalized to them, (3) the ease of use, and (4) beliefs about their own drinking behaviors. Participants recommended that the app would be most suitable for personnel about to leave the Armed Forces.

Conclusions

InDEx was an acceptable smartphone app for ex-serving personnel for monitoring alcohol consumption and in providing meaningful feedback to the individual. Pages that met the participant’s interests and provided real time personalized, credible feedback on their drinking and text messages tailored to participant’s interactions with the app were particularly favored.

Mental Health, Help-Seeking Behaviour and Social Support in the UK Armed Forces by Gender

Background: Little is known about gender differences in mental health, related help-seeking behavior and social support in UK military personnel. Methods: 1714 UK military serving personnel and ex-service veterans were randomly selected if, in a cohort study, they endorsed experiencing a subjective stress, emotional, alcohol or mental health problem in the previous three years. Following exclusions, the final sample size was 1448 (participation rate 84.5%; women n = 219). Structured telephone interviews assessed anxiety, depression, PTSD symptoms, alcohol use, help-seeking and social support occurring both currently and in the past three years. Outcomes were assessed using weighted unadjusted and adjusted logistic regression analyses. Results: Mental health problems assessed at interview were broadly similar for men and women; for both genders, levels of social support were high. One-fifth of respondents screened positive for probable mental disorder or alcohol misuse; although rates of mental disorder symptoms did not differ by gender, women were significantly less likely than men to report alcohol misuse. Women were significantly more likely to have sought help from formal medical sources but significantly less likely to access informal support such as friends, family or unit welfare sources; reasons for seeking formal medical support were similar for men and women except for problem recognition and acting on advice from others, which were both significantly more common among women. Conclusion: For military personnel with a history of mental ill-health, women should make greater use of informal support networks while for men, engagement with formal medical help sources should be encouraged.