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.

Where are all the veterans? A mixed methods assessment of a systematic strategy to increase veteran registration in UK primary healthcare practices

OBJECTIVES

To identify effective initiatives to increase veteran registration in UK primary healthcare (PHC) practices.

DESIGN

A structured and systematic strategy was designed to improve the number of military veterans correctly coded within PHC. A mixed methods approach was adopted to evaluate the impact. PHC staff provided anonymised patient medical record data that used Read and Systematised Nomenclature of Medicine - Clinical Terms codes to identify the number of veterans within each PHC practice. This included baseline data, then scheduled further information after two phases of internal advertisement and two phases of external advertisement of different initiatives intended to raise veteran registration. Qualitative data was acquired through post-project interviews with PHC staff to ascertain the effectiveness, benefits, problems and means for improvement. A modified Grounded theory was used for the 12 staff interviews.

SETTING AND PARTICIPANTS

Twelve PHC practices in Cheshire, England, participated in this research study with a combined total of 138 098 patients. Data was collected between 01 September 2020 until 28 February 2021.

RESULTS

Overall, veteran registration increased by 218.1% (N=1311). Estimated coverage of veterans increased from a coverage of 9.3% to a coverage of 29.5%. There was an increased population coverage ranging from 5.0% to 54.1%. The staff interviews revealed improved staff commitment and their taking ownership of the responsibility to improve veteran registration. The primary challenge was the COVID-19 pandemic, in particular the significantly reduced footfall and the communication opportunities and interface with patients.

CONCLUSIONS

Managing an advertising campaign and improving veteran registration during a pandemic caused huge problems, but it also presented opportunities. Enabling a significant increase in PHC registration during the harshest and most testing conditions indicates that the accomplished achievements have substantial merit for wider adoption and impact.

An evaluation of the veteran friendly practice accreditation programme

BACKGROUND

The Royal College of General Practitioners Veteran Friendly Practice Accreditation Programme launched in 2019, aiming to allow practices to better identify, treat and refer veterans, where appropriate, to dedicated NHS services.

AIM

Evaluate the effectiveness of the accreditation programme, focusing on benefits for the veteran, the practice and the delivery of the programme itself.

DESIGN & SETTING

The study evaluated the views of Veteran Friendly Accredited GP Practices across England.

METHOD

Mixed-methods study collecting data via an online survey from 232 accredited Primary Healthcare (PHC) staff and 15 semi-structured interviews with PHC Veteran Leads. Interviews were analysed using modified Grounded Theory.

RESULTS

99% (N=228) of respondents would recommend the programme, 77% (N=124) reported improved awareness and 84% (N=193) a better understanding of veteran's needs. 72% (N=166) identified benefits for veterans who were engaging more with PHC but participants felt more time was needed, largely due to the Covid-19 pandemic, to fully assess the impact of the programme on help-seeking behaviour. Challenges included identifying veterans already registered, promoting the accreditation process and ensuring all PHC staff were kept up to date with veteran issues.

CONCLUSIONS

The programme has increased signposting to veteran specific services and greater understanding of the NHS priority referral criteria for veterans. Recording of veteran status has improved and there was evidence of a better medical record coding system in PHC practices. These findings add to the limited empirical evidence exploring veteran engagement in PHC and demonstrate how accreditation results in better treatment and identification of veterans.

"We Got an Invite into the Fortress": VA-Community Partnerships for Meeting Veterans' Healthcare Needs

Responding to identified needs for increased veterans' access to healthcare, in 2010 the United States Department of Veterans Affairs (VA) launched the Veteran Community Partnership (VCP) initiative to "foster seamless access to, and transitions among, the full continuum of non-institutional extended care and support services in VA and the community". This initiative represents an important effort by VA to promote collaboration with a broad range of community organizations as equal partners in the service of veteran needs. The purpose of the study is an initial assessment of the VCP program. Focus group interviews conducted in six sites in 2015 included 53 representatives of the local VA and community organizations involved with rural and urban VCPs across the US. Interview topics included the experiences and practices of VCP members, perceived benefits and challenges, and the characteristics and dynamics of rural and urban areas served by VCPs. Using a community-oriented conceptual framework, the analyses address VCP processes and preliminary outcomes, including VCP goals and activities, and VCP members' perceptions of their efforts, benefits, challenges, and achievements. The results indicate largely positive perceptions of the VCP initiative and its early outcomes by both community and VA participants. Benefits and challenges vary by rural-urban community context and include resource limitations and the potential for VA dominance of other VCP partners. Although all VCPs identified significant benefits and challenges, time and resource constraints and local organizational dynamics varied by rural and urban context. Significant investments in VCPs will be required to increase their impacts.

Veteran help-seeking behaviour for mental health issues: a systematic review

INTRODUCTION

Serving military personnel and veterans have been identified to have a high prevalence of mental health disorders. Despite this, only a significantly small number seek mental healthcare. With the UK beginning to invest further support to the armed forces community, identification of barriers and facilitators of help-seeking behaviour is needed.

METHODS

Corresponding literature search was conducted in PsycINFO, PsycArticles, Medline, Web of Science and EBSCO. Articles which discussed barriers and facilitators of seeking help for mental health concerns in the veteran population were included. Those which discussed serving personnel or physical problems were not included within this review. A total of 26 papers were analysed.

RESULTS

A number of barriers and facilitators of help-seeking for a mental health issue within the veteran population were identified. Barriers included stigma, military culture of stoicism and self-reliance, as well as deployment characteristics of combat exposure and different warzone deployments. Health service difficulties such as access and lack of understanding by civilian staff were also identified. Facilitators to help combat these barriers included a campaign to dispel the stigma, including involvement of veterans and training of military personnel, as well as more accessibility and understanding from healthcare staff.

CONCLUSIONS

While some barriers and facilitators have been identified, much of this research has been conducted within the USA and on male veterans and lacks longitudinal evidence. Further research is needed within the context of other nations and female veterans and to further indicate the facilitators of help-seeking among veterans.

Critical analysis of the Armed Forces Covenant Fund Trust Aged Veterans Fund

BACKGROUND

Relatively little research is available regarding the specific needs of older military veterans and the services introduced to support them. In 2016, the Armed Forces Covenant Fund Trust launched the Aged Veterans Fund (AVF), to understand the impact that military service may have on ageing, and to support initiatives targeting their health and well-being. This fund was financed for 5 years and included 19 UK portfolio projects.

METHOD

The paper presents a retrospective evaluation on the processes and impact of the AVF, with the intent of informing policy, educational services, service providers and stakeholders of the lessons learnt. The inclusion criteria was veterans and their families aged 65 years of age or over. In 2019, data were drawn from documentary evidence related to the programmes. Qualitative analysis were performed on 78 eligible sources and 10 themes were identified.

RESULTS

Programmes were rolled out via collaborative partnerships referrals, focusing on person-centred or skill-exchange approaches. Challenges were encountered, such as capacity and timelines issues. A limited amount of associated cost-savings was observed, even if examples of sustainability and high satisfaction were reported. Evidence was found of programmes boosting health and well-being outcomes, in raising awareness, and in positively impacting on clinical practice, such as re-admission rates.

CONCLUSION

The AVF programmes were successful in their intent to provide support to older veterans and their families. The findings provide indicators of the next steps required for the support of ageing veterans. Further investigation of the cost-effectiveness of age-friendly veterans' services is needed.

National Health Service interventions in England to improve care to Armed Forces veterans

Armed Forces veterans (AFVs) are first and foremost citizens of the UK and are therefore—like all UK residents—entitled to universal healthcare, free at the point of need. This means that AFVs have nearly all their healthcare needs met by the NHS, which provides access to a full range of generic services. However, since 2013 there has been an Armed Forces team that can also support veterans. This review is an assessment of the work of this group over the last eight years. The health needs of AFVs have been investigated and are not significantly different from those of their demographically matched peers. However, due to their demographics, selection at recruitment and their roles, AFVs compared with the general population are more likely to be male, white and old and have fewer pre-existing or hereditary conditions. However, they do suffer from higher rates of musculoskeletal injury, different patterns of mental health illness and have historically been higher users—and abusers—of alcohol and tobacco. In addition to supporting mainstream services used by AFVs, the NHS in England commissions a bespoke range-specific ‘Priority’ NHS services such as those for mental health or for rehabilitation of veterans using prostheses. New interventions are continuing to be developed to improve AFVs’ healthcare and are aligned to the NHS Long Term Plan and the restoration and recovery plans after the COVID-19 pandemic.

Evaluating serious stress in military veterans, their carers and families: a protocol

In 2018, the Armed Forces Covenant Fund Trust (ACFT) allocated approximately £4M to seven UK projects to address serious stress in military veterans, their carers and families. These programmes commenced between May and October 2019 and will conclude in August 2021.

This paper outlines the protocol for the evaluation of the Tackling Serious Stress programme and the novel support provided to grant holders. Entry into the programmes was through multiple routes, including self-referrals with an anticipated sample of approximately 2000 participants. A common outcomes framework was designed to measure outcomes. Grant holders accepted ownership for data collection and quality and were supported through accompanying guidance material.

Veterans were often reluctant to seek support, and the anonymous and confidential nature of the evaluation plus the study team’s military background helped address this. Participants’ voices were a key part in developing the protocol, leading to results to inform policy and highlight success, efficiency and cost effectiveness, and providing markers for future development.

The study provided a reservoir of information. Interim reports indicated compliance with performance indicators and provided timely evidence. Shared learning provided grant holders with an indication of what was helping the beneficiaries and what needed to be improved. The combination of all data sets provided the ACFT with a resource to demonstrate success and insight into projects where improvement was required, and indicators of how to redress these problems. The study protocol provided a platform for building lasting partnerships.

Housing Needs of Ageing Veterans Who Have Experienced Limb Loss

Military veterans can experience limb loss as a direct result of conflict, an accident, illness or injury. Whatever the cause, there is a need to recognise the long-term consequences and challenges of limb loss on maintaining independence in one’s home. This study aimed to examine the housing needs of veterans experiencing limb loss, and the impact of limb loss on housing needs and home adaptations of ageing military veterans. Thirty-two military veterans (aged 43–95) participated in this study and up to three life-story interviews were carried out with each participant. Two themes were generated: availability of support and changing housing needs. It is evident from the findings that military veterans are unique in various ways, specifically due to military culture, geographical relocation and the additional support that is available to the Armed Forces Community. This must be considered in long-term support to maintain independence in the home.

Perceptions of health and healthcare in ex-Army residents of Tameside: a pilot qualitative study

BACKGROUND

Local authorities and other service providers need data on their local ex-military communities to be able to plan services. However, published research and data may not be applicable to the local population. Qualitative research offers a relatively low-cost way to get insights into the needs of local ex-military communities.

METHODS

A pilot study using in-depth interviews with a small convenience sample of former ex-Army residents of Tameside. Framework analysis was used to identify and group themes arising from the data. This study was conducted using the Consolidated Criteria for Reporting Qualitative Research.

RESULTS

While participants saw mental health as a particular challenge, they felt that it tends to get disproportionate attention relative to other needs. The study identified potential barriers to accessing health services that arise from an interaction between aspects of military and civilian healthcare culture and practices. Participants also said that military service could affect the health of both partners and children and that these effects might be more pronounced at key times, such as during adolescence.

CONCLUSION

Participants' perceptions of the health of former members of the Armed forces reflect the published epidemiological literature. This suggests that qualitative data can be valid for understanding the health needs of local ex-military communities. Further research is needed to test the findings here with a broader group of ex-military personnel, to explore the barriers faced in accessing healthcare and to understand the health needs of the families of ex-service personnel.