Patterns of drinking in the UK Armed Forces

The role of emotion regulation in decreasing alcohol harm for veterans

Using the socio-ecological model, this study aims to understand factors associated with alcohol misuse in veterans of the New Zealand Defence Forces, and identify approaches for reducing harm. Using interviews, veterans were asked to recount their relationship to alcohol, and provide a narrative of its use before, during and after military service. Seven themes were identified including bars and drinking as 1) social hubs; and 2) social lubrication; providing others with 3) duty of care; the military 4) consequences of harmful drinking; and use of alcohol as 5) emotion regulation strategies; with the impact of that on 6) Civvy street, and 7) family impacts. Duty of care in military drinking environments is a new theme to the literature. Introducing emotion regulation training throughout the personnels' career, from transition to becoming civilians and beyond, was identified as key to effective health marketing interventions.

The DrinksRation Smartphone App for Modifying Alcohol Use Behaviors in UK Military Service Personnel at Risk of Alcohol-Related Harm: Protocol for a Randomized Controlled Trial

BACKGROUND

Consumption of alcohol is synonymous with military populations, and studies have shown that serving personnel drink more than age- and sex-matched civilian populations. While ingrained in the military culture, excessive alcohol use is associated with increased rates of disciplinary issues, sickness absence, and loss of productivity, as well as contributing to a burden of acute and chronic health problems. Alcohol brief interventions can reduce alcohol use in civilian populations, but there is a paucity of evidence relating to the effectiveness of similar interventions in military populations. The DrinksRation smartphone app was designed to have a basis in behavior change technique theory and focuses on providing interactive behavioral prompts tailored to a military population. It has previously been shown to be effective in a help-seeking veteran population.

OBJECTIVE

The primary aim of the Military DrinksRation randomized controlled trial study is to determine whether it is similarly effective in a serving military population.

METHODS

We compare the effectiveness of the DrinksRation smartphone app with treatment as usual for personnel identified at risk of alcohol-related harm using the Military DrinksRation study that is a 2-arm, single-blind, 1:1 randomized controlled trial of the UK Armed Forces population. It is hypothesized that the DrinksRation app will be more efficacious at reducing alcohol consumption compared to treatment as usual. Recruitment will be predominantly from routine, periodic dental inspections all service personnel regularly undertake, supplemented by recruitment from military-targeted media messaging. The primary outcome is the change in alcohol units consumed per week between baseline and day 84, measured using the timeline follow-back method. Secondary outcome measures are a change in the Alcohol Use Disorders Identification Test score, a change in the quality of life assessment, and a change in drinking motivations and app usability (intervention arm only) between baseline and day 84. A final data collection at 168 days will assess the persistence of any changes over a longer duration.

RESULTS

The study is expected to open in August 2023 and aims to enroll 728 participants to allow for a study sample size requirement of 218 per arm and a 40% attrition rate. It is expected to take up to 12 months to complete. The results will be published in 2024.

CONCLUSIONS

The Military DrinksRation study will assess the efficacy of the smartphone app on changing alcohol use behaviors in service personnel. If a positive effect is shown, the UK Defence Medical Services would have an effective, evidence-based tool to use as part of an alcohol management clinical pathway, thereby providing better support for military personnel at risk of harm from alcohol drinking.

TRIAL REGISTRATION

ISRCTN Registry 42646;. https://doi.org/10.1186/ISRCTN14977034.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/49918.

Calibrating the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) for detecting alcohol-related problems among Canadian, UK and US soldiers: cross-sectional pre-deployment and post-deployment survey results

OBJECTIVES

Excessive alcohol use can bring about adverse health and work-related consequences in civilian and military populations. Screening for excessive drinking can help identify individuals at risk for alcohol-related problems who may require clinical interventions. The brief validated measures of alcohol use such as the Alcohol Use Disorders Identification Test (AUDIT), or abbreviated AUDIT-Consumption (AUDIT-C), are often included in military deployment screening and epidemiologic surveys, but appropriate cut-points must be used to effectively identify individuals at risk. Although the conventional AUDIT-C cut-points ≥4 for men and ≥3 for women are commonly used, recent validation studies of veterans and civilians recommend higher cut-points to minimise misclassification and overestimation of alcohol-related problems. This study aims to ascertain optimal AUDIT-C cut-points for detecting alcohol-related problems among serving Canadian, UK and US soldiers.

DESIGN

Cross-sectional pre/post-deployment survey data were used.

SETTINGS

Comprised Army locations in Canada and UK, and selected US Army units.

PARTICIPANTS

Included soldiers in each of the above-mentioned settings.

OUTCOME MEASURES

Soldiers' AUDIT scores for hazardous and harmful alcohol use or high levels of alcohol problems served as a benchmark against which optimal sex-specific AUDIT-C cut-points were assessed.

RESULTS

Across the three-nation samples, AUDIT-C cut-points of ≥6/7 for men and ≥5/6 for women performed well in detecting hazardous and harmful alcohol use and provided comparable prevalence estimates to AUDIT scores ≥8 for men and ≥7 for women. The AUDIT-C cut-point ≥8/9 for both men and women performed fair-to-good when benchmarked against AUDIT ≥16, although inflated AUDIT-C-derived prevalence estimates and low positive predictive values were observed.

CONCLUSION

This multi-national study provides valuable information regarding appropriate AUDIT-C cut-points for detecting hazardous and harmful alcohol use, and high levels of alcohol problems among soldiers. Such information can be useful for population surveillance, pre-deployment/post-deployment screening of military personnel, and clinical practice.

Suicide Risk, Alcohol Consumption and Attitudes towards Psychological Help-Seeking among Lithuanian General Population Men, Conscripts and Regular Active Duty Soldiers

The aim of this study was to investigate the relationship between suicide risk, alcohol consumption, and attitudes towards professional psychological help among Lithuanian general population men, conscripts, and regular active duty (AD) soldiers. In total, 1195 Lithuanian adult males participated in the study: 445 men from the general population, 490 conscripts, and 260 regular AD soldiers from the Lithuanian Armed Forces. The study's measures included: general suicide risk, alcohol consumption levels, frequency of using alcohol as a means to suppress difficult thoughts and feelings, and attitudes toward psychological help. Both military samples showed significantly lower suicide risk than men from the general population. Alcohol use as a means to suppress difficult thoughts and feelings was the most significant predictor of suicide risk and a significant mediator between alcohol consumption and suicide risk in all study groups. Another significant suicide risk predictor and mediator between alcohol consumption and suicide risk-i.e., the value of seeking psychological treatment-was found only in the conscript sample. Results of the current study suggest that there is an opportunity for intervention aimed at the attitudes toward seeking professional psychological help for conscripts. However, that might not be the case for regular AD soldiers, nor the general population of Lithuanian men.

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.

Does Drinking Culture Induce Problematic Alcohol Use? Evidence From a Military Representative Survey in Korea

OBJECTIVE

To examine the relationship between problematic alcohol use and contributing factors among Korean professional soldiers.

METHODS

Cross-sectional data of 2,646 participants collected by 2014 military-wide representative health survey was analyzed. Multivariate logistic models were used to identify contributing factors for problematic alcohol use. Problematic alcohol use was defined by the Alcohol Use Disorders Identification Test (AUDIT) questionnaire as hazardous (8≤ AUDIT <16) or harmful (AUDIT ≥16). Tolerant drinking culture was measured by the Drinking Culture Questionnaire.

RESULTS

Hazardous alcohol use was found in 56.9% of men and 46.8% of women and harmful use in a further 16.2% of men and 5.4% of women. In univariate analyses, perceived health status, subjective sleep quality, depression, and drinking culture were related to the outcome variable. In multivariate models controlling covariates, the likelihood of problematic alcohol use was significantly increased by man gender, being single, current/past smoking, and tolerant/permissive drinking culture. In those with harmful alcohol consumption, tolerant drinking culture was a particularly powerful influence.

CONCLUSION

A substantial proportion of Korean professional soldiers demonstrated problematic alcohol use. Tolerant drinking culture was shown to have a significant influence on problematic alcohol use in the military. Our findings underscore the need for public health policies that address this drinking culture to mitigate negative health consequences and preserve the forces' combat readiness.

Military service and alcohol use: a systematic narrative review

Background

Despite research highlighting the role of alcohol in military life, specifically in relation to mental health and certain combat experiences, there is no synthesised evidence looking at the relationship between military service and alcohol use.

Aims

To synthesize and examine evidence exploring the relationship between military service and alcohol use.

Methods

Six databases were examined across a 10-year period. Papers were included if they involved a military population and focused on alcohol use. From 4046 papers identified, 29 papers were included in the review.

Results

Military characteristics and experience were linked to high levels of alcohol use across military populations. Societal and cultural factors also played a role in alcohol use in military populations. Predatory behaviour of alcohol establishments, pressures to conform, an acceptance of alcohol use, and the role of religious services and military affiliated social networks were all considered. Excessive drinking impacted physical and mental health. Those diagnosed with PTSD and associated symptoms appeared to have greater alcohol use.

Conclusions

This review identified certain characteristics and experiences of military service that are associated with higher levels of alcohol use. It is important to identify risk factors for alcohol misuse to develop appropriate policy, targeting prevention.

Developing an Integrated Model of Care for Veterans with Alcohol Problems

Introduction:

Veterans often do not present with alcohol problems in isolation, they may have a wide range of social, physical, and psychological needs. The aim of this study was to facilitate the development of a co-designed integrated model of care for veterans with alcohol problems.

Methods:

Following the development model by the Agency for Clinical Innovation, a planning symposium was held in North East of England to engage health and social care planners, public health leads, clinical commissioning groups and providers. Service users were empowered in discussions to provide insights and look for solutions (N = 43).

Results:

Using diagramming techniques, three examples of health and social care provision were created demonstrating the current commissioning landscape, one veteran’s experience of accessing services and a proposal for a new integrated model of care for veterans with alcohol problems.

Discussion:

By engaging stakeholders and service users, the model proposed a potential solution to reducing the number of veterans ‘falling through the gaps’ or disengaging from services. The collaborative approach highlighted the difficulties in navigating the current complex health and social care systems. The co-designed hub and spoke model aims to enable alcohol misuse services to adapt and evolve so that they better fit the needs of veterans.

Trajectories of alcohol misuse among the UK Armed Forces over a 12-year period

AIM

To identify the main trajectories of alcohol misuse among UK military personnel from 12 years after the start of the Iraq war (2003) and the factors associated with each trajectory.

DESIGN

Longitudinal cohort study with three phases of data collection (2004-06, 2007-09 and 2014-16).

SETTING

United Kingdom.

PARTICIPANTS

Serving and ex-serving personnel of the UK Armed Forces (n = 7111) participating at Phase 1 and at least one follow-up phase of the King's Centre for Military Health Research (KCMHR) cohort study.

MEASUREMENTS

Trajectories of alcohol misuse were derived from scores using the Alcohol Use Disorders Identification Test (AUDIT-10) over three data collection phases. Demographic and military characteristics were collected and, among the key covariates, post-traumatic stress disorder (PTSD) was measured using the PTSD checklist (PCL-C) and childhood interpersonal stress and violence was measured using items from the Adverse Childhood Experiences questionnaire.

FINDINGS

Five trajectories of alcohol misuse were identified, including 'no misuse' (n = 2249, 31.6%) and 'hazardous' (n = 3398, 47.8%), 'harmful' (n = 832, 11.7%), 'severe-to-hazardous' (n = 258, 5.3%) and 'severe' (n = 374, 3.6%) drinking. Substantial changes were evident only among severe drinkers, where more than half reduced over the study period. The factors most strongly associated with belonging to harmful/severe drinking classes were young age, male gender and childhood adversities and antisocial behaviour. Severe drinkers at Phase 1 were more likely to report probable PTSD and shorter military careers and were less likely to serve as Officers. Persistent severe drinkers were less likely to serve in the RAF compared to the Army and were more likely to be reserves. Not misusing alcohol was also associated with reserve status and having left service.

CONCLUSIONS

In a cohort of approximately 7000 UK military personnel, trajectories of alcohol misuse appeared stable between 2004 and 2016. More than half of severe drinkers made substantial improvements over the period, but 68% of the cohort continued to drink hazardously or harmfully. Lack of change for the majority of the sample signals the need for strategies to address alcohol misuse and its cultural and psychosocial drivers.

Mental health disorders and alcohol misuse among UK military veterans and the general population: a comparison study

BACKGROUND

For a small minority of personnel, military service can have a negative impact on their mental health. Yet no studies have assessed how the mental health of UK veterans (who served during the recent operations in Afghanistan or Iraq) compares to non-veterans, to determine if they are at a disadvantage. We examine the prevalence of mental disorders and alcohol misuse in UK veterans compared to non-veterans.

METHODS

Veteran data were taken from the third phase of the King's Centre for Military Health Research cohort study (n = 2917). These data were compared with data on non-veterans taken from two large general population surveys: 2014 Adult Psychiatric Morbidity Survey (n = 5871) and wave 6 of the UK Household Longitudinal Study (UKHLS, n = 22 760).

RESULTS

We found that, overall, UK veterans who served at the time of recent military operations were more likely to report a significantly higher prevalence of common mental disorders (CMD) (23% v. 16%), post-traumatic stress disorder (PTSD) (8% v. 5%) and alcohol misuse (11% v. 6%) than non-veterans. Stratifying by gender showed that the negative impact of being a veteran on mental health and alcohol misuse was restricted to male veterans. Being ill or disabled was associated with a higher prevalence of CMD and PTSD for both veterans and non-veterans.

CONCLUSION

Whilst the same sociodemographic groups within the veteran and non-veteran populations seemed to have an increased risk of mental health problems (e.g. those who were unemployed), male veterans, in particular, appear to be at a distinct disadvantage compared to those who have never served.

Differences in problem alcohol drinking by military service type among male professional military personnel in South Korea using Military Health Survey data

OBJECTIVES

Alcohol drinking prevalence in Korea is higher than in other countries and is associated with various social and health problems. Korean culture tends to be tolerant of alcohol drinking and to regard it as an important medium for maintaining good interpersonal relationships in one's social life. Although alcohol drinking is a means of relieving stress, especially among soldiers, who engage in more binge drinking than civilians, there is lack of research focused on problem drinking among soldiers. Therefore, the purpose of this study was to explore the extent of problem drinking across all military services and to identify factors associated with problem drinking by military service type.

DESIGN

Secondary data analysis.

SETTING

Dataset of the Military Health Survey in 2015.

PARTICIPANTS

Altogether, 2252 male professional military personnel were included in this study.

MAIN OUTCOME MEASURE

Problem drinking in this study was defined as at-risk drinking and alcohol abuse or dependence with an Alcohol Use Disorders Identification-Korean (AUDIT-K) score of 10 points or higher.

RESULTS

The average AUDIT-K score was 7.38±4.10 points. The prevalence of problem drinking was 16.4% for the Army, 34.5% for the Navy and 32.1% for the Air Force. Factors associated with problem drinking for each military service type were sleep satisfaction (OR 2.33, 95% CI 1.284 to 4.236) and family support (OR 0.66, 95% CI 0.487 to 0.904) in the Army, smoking status (OR 1.85, 95% CI 1.130 to 3.039) and sleep satisfaction (OR 2.29, 95% CI 1.142 to 4.574) in the Navy and marital status (OR 0.60, 95% CI 0.382 to 0.951), smoking (past smokers and non-smokers OR 2.81, 95% CI 1.593 to 4.973, current smokers and non-smokers OR 1.68, 95% CI 1.114 to 2.544), subjective oral health (OR 1.83, 95% CI 1.011 to 3.297) and family support (OR 0.63, 95% CI 0.45 to 0.88) in the Air Force.

CONCLUSION

When implementing health projects to address drinking problems, it is necessary to ensure that service-type-specific factors are considered for integrated management.

Workplace victimization and alcohol misuse among junior military personnel: Mediating the role of anger

BACKGROUND

Workplace victimization is one of most serious problems for affecting alcohol misuse in junior military personnel (JMP) that has been largely overlooked in research attention. Studies on workplace victimization and alcohol misuse indicate anger as mediator. Workplace victimization may affect alcohol misuse (in)directly through the mediator.

METHODS

A sample of JMP (N = 815) completed an offline survey, consisting of the revised Conflict Tactics Scale-2, Composite International Diagnostic Interview Screening Scale, and the Alcohol Use Disorders Identification Test. Frequency, t-test and chi-square test, and mediation analyses were conducted to assess the effects of workplace victimization on alcohol misuse, mediated via anger.

RESULTS

Victims in the workplace showed higher level of anger and alcohol misuse. In mediation analyses, workplace victimization was related to higher levels of anger, which, in turn, were associated with greater alcohol misuse.

LIMITATIONS

Study limitations included the use of cross-sectional data with the use of retrospective self-report.

CONCLUSION

Workplace victimization in JMP is prevalent (17.7%), and alcohol misuse is associated with effects of workplace victimization and anger with full mediation path. Findings suggest that eliminating workplace victimization against JMP and intervention for anger should be focused upon, and implemented for online alcohol misuse prevention in the military context.

Psychiatric Disorders among the Military in West Africa: A Systematic Narrative Review

(1) Background: Military combat impacts the mental health of veterans and active military personnel. Although various studies, the majority of which are from Westernized countries, have provided insight into how combat causes psychiatric disorders, such as post-traumatic stress disorder (PTSD), depression, and anxiety among veterans, there appears to be scant published literature on psychiatric disorders among military personnel in the West African region. It is important to contextually understand the psychiatric disorders among military personnel in this region who may be faced with similar vulnerabilities to their counterparts from Western cultures. (2) Methods: This study follows the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they were published in English between January 2010 and January 2021 and assessed mental health problems or psychiatric disorders among soldiers in West Africa. (3) Results: All three included studies were from Nigeria. High prevalence rates of substance and alcohol use were reported. (4) Conclusions: This review highlights the need for more research in this population as well as identifying the intervention needs of the soldiers and their implications.

The prevalence of hazardous and harmful alcohol use across trauma-exposed occupations: A meta-analysis and meta-regression

BACKGROUND

Trauma exposure is associated with hazardous and/or harmful alcohol use. Occupational groups frequently exposed to trauma may be at risk of alcohol harm. This meta-analysis determined the prevalence of hazardous and harmful alcohol use across trauma-exposed occupations and meta-regressions explored the impact of pre-defined covariates on the variance in prevalence estimates.

METHOD

Literature was searched from 2000 to March 2020, using Scopus, Web of Science and PsycINFO. Studies were included in the meta-analysis if they used a standardized measure of alcohol use (e.g., Alcohol Use Disorder Identification Test (AUDIT)). Studies were excluded if they measured alcohol use following an isolated sentinel event (e.g., 9/11). The following occupations were included: first responders, health care workers, Armed Forces, war journalists and train drivers.

RESULTS

1882 studies were identified; 55 studies were eligible. The pooled prevalence of hazardous use was 22% (95% Confidence Intervals [CI]: 17%-27%) and 11% (95% CI: 8%-14%) for harmful use. Hazardous alcohol use was significantly lower in health care workers (13%; 95% CI: 10%-16%) than first responders (26%; 95% CI: 20%-32%) and Armed Forces (34%; 95% CI: 18%-52%). There was marked heterogeneity across studies and higher prevalence rates in low-quality studies. The meta-regression identified higher proportion of males and younger mean age as predictors of variance.

CONCLUSIONS

Male-dominated occupations, such as police officers and military personnel, showed higher levels of hazardous and harmful alcohol use, indicating that interventions tailored specifically for these occupational groups may be needed.

Military and demographic predictors of mental ill-health and socioeconomic hardship among UK veterans

BACKGROUND

Around 8% of the UK Armed Forces leave in any given year, and must navigate unfamiliar civilian systems to acquire employment, healthcare, and other necessities. This paper determines longer-term prevalences of mental ill health and socioeconomic outcomes in UK Service leavers, and how they are related to demographic factors, military history, and pre-enlistment adversity.

METHODS

This study utilised data from a longitudinal sample of a cohort study UK Armed Forces personnel since 2003. A range of self-reported military and sociodemographic factors were analysed as predictors of probable Post-Traumatic Stress Disorder, common mental disorders, alcohol misuse, unemployment and financial hardship. Prevalences and odds ratios of associations between predictors and outcomes were estimated for regular veterans in this cohort.

RESULTS

Veteran hardship was mostly associated with factors linked to socio-economic status: age, education, and childhood adversity. Few military-specific factors predicted mental health or socio-economic hardship, except method of leaving (where those leaving due to medical or unplanned discharge were more likely to encounter most forms of hardship as veterans), and rank which is itself related to socioeconomic status.

CONCLUSION

Transition and resettlement provisions become increasingly generous with longer service, yet this paper shows the need for those services becomes progressively less necessary as personnel acquire seniority and skills, and instead could be best targeted at unplanned leavers, taking socioeconomic status into consideration. Many will agree that longer service should be more rewarded, but the opposite is true if provision instead reflects need rather than length of service. This is a social, political and ethical dilemma.

Alcohol use disorder in active duty service members: Incidence rates over a 19-year period

Background: Alcohol use is a concerning issue for the military given its potential negative impact on human performance. Limited data are available regarding the incidence of alcohol use disorder in the military, which is critical to understand to evaluate force readiness, as well as for preventative initiatives and treatment planning. The aim was to examine the alcohol use disorder incidence rates (overall and across demographics) among active duty service members from 2001 to 2018. Methods: Data on 208,870 active duty service members between 2001 and 2018 from the Defense Medical Epidemiology Database was examined. Incidence rates were analyzed to determine the diagnostic rates of AUD (including both alcohol abuse and dependence), which were then examined by sex, age, service branch, military pay grade, marital status, and race. Results: Incidence rates of AUD in active duty service members (per 1,000 service members) ranged from 6.45 to 10.50 for alcohol abuse and 5.21 to 7.11 for alcohol dependence. Initial diagnoses of new-onset AUD occurred most frequently within 20-24 year-old, white, male, and non-married U.S. Army service members in the enlisted pay grades of E-1 to E-4. Statistically significant differences (p <.001) were found between observed and expected counts across all examined demographic variables. Conclusions: To our knowledge, this is the first study to provide a comprehensive examination of AUD incidence rates in an active-duty military population over an extended 18-year period and during the last decade. Incidence rates were higher than expected for alcohol dependence and lower than expected for alcohol abuse. Given the untoward effects of AUD on overall health and force readiness, active-duty service members may benefit from more advanced preventative interventions to decrease incidence rates of AUD over time. Future research should use these data to develop targeted interventions for the demographics at greatest risk.

Military-related posttraumatic stress disorder and mindfulness meditation: A systematic review and meta-analysis

PURPOSE

Posttraumatic stress disorder (PTSD) is a significant global mental health concern, especially in the military. This study aims to estimate the efficacy of mindfulness meditation in the treatment of military-related PTSD, by synthesizing evidences from randomized controlled trials.

METHODS

Five electronic databases (Pubmed, EBSCO Medline, Embase, PsychINFO and Cochrane Library) were searched for randomized controlled trials focusing on the treatment effect of mindfulness meditation on military-related PTSD. The selection of eligible studies was based on identical inclusion and exclusion criteria. Information about study characteristics, participant characteristics, intervention details, PTSD outcomes, as well as potential adverse effects was extracted from the included studies. Risk of bias of all the included studies was critically assessed using the Cochrane Collaboration's tool. R Statistical software was performed for data analysis.

RESULTS

A total of 1902 records were initially identified and screened. After duplicates removal and title & abstract review, finally, 19 articles in English language with 1326 participants were included through strict inclusion and exclusion criteria. The results revealed that mindfulness meditation had a significantly larger effect on alleviating military-related PTSD symptoms compared with control conditions, such as treatment as usual, present-centered group therapy and PTSD health education (standardized mean difference (SMD) = -0.33; 95% CI [-0.45, -0.21]; p < 0.0001). Mindfulness interventions with different control conditions (active or non-active control, SMD = -0.33, 95% CI [-0.46, -0.19]; SMD = -0.49, 95% CI [-0.88, -0.10], respectively), formats of delivery (group-based or individual-based, SMD = -0.30, 95% CI [-0.42, -0.17], SMD = -0.49, 95% CI [-0.90, -0.08], respectively) and intervention durations (short-term or standard duration, SMD = -0.27, 95% CI [-0.46, -0.08], SMD = -0.40, 95% CI [-0.58, -0.21], respectively) were equally effective in improving military-related PTSD symptoms.

CONCLUSION

Findings from this meta-analysis consolidate the efficacy and feasibility of mindfulness meditation in the treatment of military-related PTSD. Further evidence with higher quality and more rigorous design is needed in the future.

The prevalence of hazardous and harmful drinking in the UK Police Service, and their co-occurrence with job strain and mental health problems

AIMS

Due to the stressful nature of policing, police employees are at risk of mental health problems and problematic alcohol use. We aim to determine the prevalence of hazardous and harmful alcohol use in the UK Police Service, and to explore the associations with job strain and mental health problems.

METHODS

Cross-sectional data from the Airwave Health Monitoring Study (N = 40 986) included measures of alcohol consumption (total units in past week), mental health (depression, anxiety and post-traumatic stress disorder [PTSD]) and job strain. The associations between mental health and job strain with alcohol consumption (i.e. abstinence, low-risk [<14 units per week, reference group], hazardous [>14 to 35 units for women, >14 to 50 units for men], harmful [>35 units for women, >50 units for men]), were analysed using multinomial logistic regressions, adjusting for potential confounders (i.e. age, gender, ethnicity, marital status, children under 18, income and smoking status).

RESULTS

A total of 32.6% of police employees reported hazardous drinking, with 3.0% drinking at harmful levels. Compared to those without a mental health problem, police employees with depression, anxiety or PTSD were twice as likely to be harmful drinkers and were also 1.3 times more likely to report abstinence. Those reporting low strain (reference group) were more likely to drink hazardously compared to those reporting high strain, which was statistically moderated by mental health. When the sample was stratified by mental health status, the association between low strain (compared to all other categories) and hazardous drinking, was significant only in those without a mental health problem.

CONCLUSIONS

These findings indicate that police employees may be an occupational group at risk of alcohol harm, with one-third drinking hazardously. The J-shaped relationship between mental health and alcohol use highlights a need for an integration of mental health and alcohol services, tailored for the UK Police Service.

Do Junior Entrants to the UK Armed Forces have worse outcomes than Standard Entrants?

INTRODUCTION

The UK is the only permanent member of the UN Security Council that has a policy of recruiting 16 and 17 year old individuals into its regular Armed Forces. Little is known about the consequences of enlisting as a Junior Entrant (JE), although concerns have been expressed. We compare the mental health, deployment history, and pre-enlistment and post-enlistment experiences of personnel who had enlisted as JEs with personnel who joined as Standard Entrants (SEs).

METHOD

Participants from a large UK military cohort study completed a self-report questionnaire between 2014 and 2016 that included symptoms of probable post-traumatic stress disorder (PTSD), common mental disorders, alcohol consumption, physical symptoms and lifetime self-harm. Data from regular non-officer participants (n=4447) from all service branches were used in the analysis. JEs were defined as having enlisted before the age of 17.5 years. A subgroup analysis of participants who had joined or commenced adult service after April 2003 was carried out.

RESULTS

JEs were not more likely to deploy to Iraq or Afghanistan but were more likely to hold a combat role when they did (OR 1.25, 95% CI 1.00 to 1.56). There was no evidence of an increase in symptoms of common mental disorders, PTSD, multiple somatic symptoms (MSS), alcohol misuse or self-harm in JEs in the full sample, but there was an increase in alcohol misuse (OR 1.84, 95% CI 1.18 to 2.87), MSS (OR 1.51, 95% CI 1.04 to 2.20) and self-harm (OR 2.13, 95% CI 1.15 to 3.95) in JEs who had commenced adult service after April 2003. JEs remain in adult service for longer and do not have more difficulties when they leave service.

CONCLUSIONS

JEs do not have worse mental health than SEs, but there is uncertainty in relation to alcohol misuse, MSS and self-harm in more recent joiners. Monitoring these concerns is advisable.

Defence dentistry: an occupationally focused health service with worldwide deployable capability

Oral disease can cause substantial disruption to service personnel, resulting in debilitation and reduced effectiveness while deployed on military operations. As such, Defence dentistry delivers an occupationally focused dental service that is deployable, agile and holistic, to ensure service personnel are dentally fit for operations and that the impact of dental morbidity is minimised.Defence dentists provide a unique service, balancing the needs of the individual while considering their operational role requirements. This enables the UK Armed Forces' oral health to be optimised by mitigating morbidity and maintaining operational capability while deployed.The aim of this paper is to highlight the key principles of Defence dentistry by discussing the public health values and occupational focus which underpin a patient-centred approach and the agility of the uniformed military dental workforce in providing a responsive and deployable care capability.

UK military veteran-friendly GP practices

About 5% of the UK population are military veterans and have specific medical needs sometimes different from the general population. Veterans may be reluctant to seek help or talk about their problems, which means they do not always access care, support and treatments that are available. Others may face difficulty getting the right help. Veterans may think ‘civilians’ do not understand military culture or know about options for help and services that are available. Experience has shown that general practitioners (GPs) would like more help and support when looking after veterans. The Royal College of General Practitioners has developed the ‘Veteran Friendly GP Practice Accreditation Programme’, which involves a simple online process of accreditation where practices are required to meet the specified criteria and provide evidence that they are supportive of veterans’ healthcare. The aim is to improve healthcare provided to veterans and their families by GPs working in primary healthcare.

Risk and protective factors for offending among UK Armed Forces personnel after they leave service: a data linkage study

BACKGROUND

A proportion of ex-military personnel who develop mental health and social problems end up in the Criminal Justice System. A government review called for better understanding of pathways to offending among ex-military personnel to improve services and reduce reoffending. We utilised data linkage with criminal records to examine the patterns of offending among military personnel after they leave service and the associated risk (including mental health and alcohol problems) and socio-economic protective factors.

METHOD

Questionnaire data from a cohort study of 13 856 randomly selected UK military personnel were linked with national criminal records to examine changes in the rates of offending after leaving service.

RESULTS

All types of offending increased after leaving service, with violent offending being the most prevalent. Offending was predicted by mental health and alcohol problems: probable PTSD, symptoms of common mental disorder and aggressive behaviour (verbal, property and threatened or actual physical aggression). Reduced risk of offending was associated with post-service socio-economic factors: absence of debt, stable housing and relationship satisfaction. These factors were associated with a reduced risk of offending in the presence of mental health risk factors.

CONCLUSIONS

Ex-military personnel are more likely to commit violent offences after leaving service than other offence-types. Mental health and alcohol problems are associated with increased risk of post-service offending, and socio-economic stability is associated with reduced risk of offending among military veterans with these problems. Efforts to reduce post-service offending should encompass management of socio-economic risk factors as well as mental health.

Workplace intervention programmes for decreasing alcohol use in military personnel: a systematic review

INTRODUCTION

Harmful or risky-single occasion drinking (RSOD) alcohol use in the military is a significant problem. However, most studies of interventions have focused on veterans, representing a missed opportunity for intervention with active military personnel. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework, the aim of this systematic review was to analyse and synthesise the evidence related to workplace-based interventions for reducing alcohol use in active-duty military personnel.

METHODS

Four electronic databases and reference lists of relevant articles were searched from database inception until 20 January 2020. This review focused on experimental and quasi-experimental studies of active-duty military personnel. Data extraction and methodological quality assessment were independently performed by two reviewers using a standardised checklist. A third reviewer was used to arbitrate the disputed studies for final selection.

RESULTS

The search yielded seven studies from an initial 1582 records identified. A range of interventions were used in these studies (four randomised controlled trials, two non-randomised trials and one before and after cohort study), including web-based approaches, telephone-delivered interventions and individual and group-based face-to-face interventions. Seven studies found decreased drinking, measured using a range of outcomes, following the intervention. However, this was not sustained in the longer term in any of the studies.

CONCLUSIONS

The low methodological rigour of most studies limited the capacity to demonstrate the efficacy of the interventions studied. Given the importance of reducing harmful or RSOD use of alcohol in the military, future studies would benefit from improved methodological rigour including ensuring adequate study power, randomisation, selection of validated outcome measures, including measures other than consumption (eg, attitudinal measures), and longer-term follow-up. There is also a need to develop methods that ensure participant loss to follow-up is minimised.

A preliminary investigation of the well-being of visually impaired ex-service personnel in the United Kingdom

Research has shown that visual impairment may impact daily functioning, health, and well-being negatively for adults of all ages. Ex-service personnel (‘veterans’) too may be at risk of poor health and well-being outcomes associated with post-military life, and this may be exacerbated by the presence of visual impairment. Despite this, research considering the experience of blind veterans has been limited and has not yet assessed well-being for these individuals across a broad spectrum of life domains. Rather, it has highlighted poor mental health and psychological well-being in working-age visually impaired veterans. However, the experiences of older visually impaired veterans (who make up the majority of visually impaired veterans in the United Kingdom) have been poorly represented in the literature. This pilot study aimed to provide a preliminary assessment of holistic well-being in an adult sample of 97 UK blind veterans, predominantly composed of older age veterans (majority over 80 years). Cross-sectional well-being data were collected using a validated measure of well-being (the Well-Being Inventory [WBI]). Results suggest that members of Blind Veterans UK are functioning well and are satisfied across four life domains (vocation, finances, health, and social relationships). Lower health satisfaction was identified, particularly in blind veterans with comorbid mental health conditions. Results are discussed in relation to the older age of the sample, the limitations of face-to-face survey administration, and the applicability of the WBI finance domain in this age cohort. Recommendations are made for future research in this population.

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.

Mental Health, Sexual Orientation, and Perceived Social Network Support in Relation to Hazardous Alcohol Consumption Among Active Duty Military Men

Knowledge surrounding perceived network support and alcohol consumption among active duty U.S. military personnel is limited, particularly among sexual minorities.We sought to determine the correlates of hazardous alcohol consumption and whether perceived network support moderated the relationship between sexual orientation and Alcohol Use Identification Test (AUDIT-C) score.The sample comprised cisgender men currently serving in the U.S. military (N = 292). Participants were recruited through respondent-driven sampling and completed an online survey. Logistic regression analysis evaluated associations between positive AUDIT-C with sociodemographic characteristics (including sexual orientation), military service, mental health, and perceived social network support. Interaction analysis assessed the moderating effect of perceived network support on sexual orientation and AUDIT-C.Among study participants, 52.7% (154/292) had positive AUDIT-C, while 65.4% (191/292) self-identified as heterosexual/straight and 34.6% (101/292) identified as gay or bisexual. In adjusted analysis, positive AUDIT-C was associated with increased post-traumatic stress disorder symptomatology (adjusted odds ratio [adjOR] 1.03; 95% CI [1.00, 1.06]; p = .019) and high perceived network support (adjOR 1.85; 95% CI [1.04, 3.29]; p = .036), while mental health service utilization had reduced odds of positive AUDIT-C (adjOR 0.40; 95% CI [0.20, 0.78]; p = .007). In interaction analysis, high perceived network support was associated with increased odds of positive AUDIT-C among sexual minority men (adjOR 3.09; 95% CI [1.21, 7.93]; p = .019) but not heterosexual men (adjOR 1.38; 95% CI [0.68, 2.81]; p = .37).Hazardous alcohol use was prevalent among all men in our sample. Perceived social network support may influence hazardous alcohol consumption, particularly among sexual minority servicemen. These findings suggest the potential role of tailored social network-based interventions to decrease hazardous alcohol use among military personnel.

The experience of health and welfare workers in identifying and responding to domestic abuse among military personnel in the UK

BACKGROUND

Awareness of domestic violence and abuse (DVA) as a problem among military personnel (serving and veterans) has grown in recent years, and there is a need for research to inform improvements in the identification of and response to DVA in this population. This study aimed to explore the experience of health and welfare professionals in identifying and responding to DVA among the UK military population (serving personnel and veterans).

METHODS

Thirty-five semi-structured telephone interviews were conducted with health and welfare staff who work with serving UK military personnel and veterans. Interviews were analysed using thematic analysis.

RESULTS

Three superordinate themes were identified: i) patterns of DVA observed by health and welfare workers (perceived gender differences in DVA experiences and role of mental health and alcohol); (ii) barriers to identification of and response to DVA (attitudinal/knowledge-based barriers and practical barriers), and iii) resource issues (training needs and access to services). Participants discussed how factors such as a culture of hypermasculinity, under-reporting of DVA, the perception of DVA as a "private matter" among military personnel, and lack of knowledge and awareness of emotional abuse and coercive controlling behaviour as abuse constitute barriers to identification and management of DVA. Healthcare providers highlighted the need for more integrated working between civilian and military services, to increase access to support and provide effective care to both victims and perpetrators. Furthermore, healthcare and welfare staff reflected on their training needs in the screening and management of DVA to improve practice.

CONCLUSIONS

There is a need for increased awareness of DVA, particularly of non-physical forms of abuse, and of male victimisation in the military. Standardised protocols for DVA management and systematic training are required to promote a consistent and appropriate response to DVA. There is a particular training need among healthcare and first-line welfare staff, who are largely relied upon to identify cases of DVA in the military. Employing DVA advocates within military and civilian healthcare settings may be useful in improving DVA awareness, management and access to specialist support.

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

Prevalence and Correlates of Mental Health Problems in Norwegian Peacekeepers 18-38 Years Postdeployment

Peacekeeping missions involve experiences that may impact the mental health of participating soldiers. However, research on the long-term mental health consequences of peacekeeping is sparse. The present study aimed to find the prevalence of mental health problems (MHPs), possible MHP predictors, and associations between predictors and MHPs in Norwegian peacekeepers 18-38 years after deployment to a United Nations peacekeeping mission. We used data from a cross-sectional, postdeployment survey of Norwegian peacekeepers who served in Lebanon between 1978 and 1998 (N = 10,605). Participants were assessed for posttraumatic stress disorder (PTSD); anxiety; depression; insomnia; alcohol misuse; drug misuse; and exposure to pre-, peri-, and postdeployment stressors. Logistic regressions were executed to explore key variables associated with MHPs. Total MHP prevalence was 15.1%, 95% CI [14.4, 15.8]. The estimates for specific disorders were 0.1% for drug misuse, 3.4% for alcohol misuse, 4.0% for depression, 6.2% for PTSD, 6.4% for anxiety, and 9.3% for insomnia. Postdeployment stressors, OR = 1.91, 95% CI [1.79, 2.04]; employment status, OR = 1.41, 95% CI [1.33, 1.48]; and traumatic exposure during deployment, OR = 1.11, 95% CI [1.09, 1.12], were positively related to PTSD, χ2(17, N = 8,568) = 1,791.299, p < .001. Similar patterns were found for the other MHPs. Considering that most participants (84.9%) reported low symptom levels, our findings challenge the widespread public perception that most peacekeepers have MHPs. Moreover, our results indicate that future peacekeepers should be prepared for challenges they may face not only during deployment but also in the years following their homecoming.

Hospital admissions for non-communicable disease in the UK military and associations with alcohol use and mental health: a data linkage study

BACKGROUND

Since the recent conflicts in Iraq and Afghanistan, the short-term focus of military healthcare research has been on the consequences of deployment for mental health and on those wounded or injured in combat. Now that these conflicts have ended for the UK Armed Forces, it is important to consider the longer term physical and mental health consequences, and just as importantly, the links between these. The aims of this study were to determine the most common physical conditions requiring a hospital admission in UK military personnel and whether they were more common in personnel with a mental health condition, smokers, and/or those misusing alcohol compared to those without.

METHODS

Data linkage of a prospective UK military cohort study to electronic admitted patient care records for England, Wales and Scotland. Nine thousand nine hundred ninety military personnel completed phase 2 of a military cohort study (56% response rate, data collected from 2007 to 2009), with analyses restricted to 86% of whom provided consent for linkage to healthcare records (n = 8602). Ninety percent were male and the mean age at phase 2 was 36 years. The outcome was physical non communicable diseases (NCDs) requiring a hospital admission which occurred after phase 2 of the cohort when the mental health, smoking and alcohol use exposure variables had been assessed until the end of March 2014.

RESULTS

The most common NCDs requiring a hospital admission were gastrointestinal disorders 5.62% (95% Confidence Intervals (CI) 5.04, 6.19) and joint disorders 5.60% (95% CI 5.02, 6.18). Number of NCDs requiring a hospital admission was significantly higher in those with a common mental disorder (Hazard ratio (HR) 1.40 (95% CI 1.16-1.68), post-traumatic stress disorder (HR 1.78 (95% CI 1.32-2.40)) and in current smokers (HR 1.35 (95% CI 1.12-1.64) compared to those without the disorder, and non-smokers, respectively.

CONCLUSIONS

Military personnel with a mental health problem are more likely to have an inpatient hospital admission for NCDs compared to those without, evidencing the clear links between physical and mental health in this population.

Prevalence of Self-Reported Intimate Partner Violence Victimization Among Military Personnel: A Systematic Review and Meta-Analysis

BACKGROUND

Research on intimate partner violence (IPV) in the military has tended to focus on military personnel as perpetrators and civilian partners/spouses as victims. However, studies have found high levels of IPV victimization among military personnel. This article systematically reviews studies of the prevalence of self-reported IPV victimization among military populations.

METHODS

Searches of four electronic databases (Embase, Medline, PsycINFO, and Web of Science) were supplemented by reference list screening. Meta-analyses of the available data were performed, where possible, using the random effects model.

RESULTS

This review included 28 studies with a combined sample of 69,808 military participants. Overall, similar or higher prevalence rates of physical IPV victimization were found among males compared to females and this was supported by a meta-analytic subgroup analysis: pooled prevalence of 21% (95% confidence interval [CI] = [17.4, 24.6]) among males and 13.6% among females (95% CI [9.5, 17.7]). Psychological IPV was the most prevalent type of abuse, in keeping with findings from the general population. There were no studies on sexual IPV victimization among male personnel. Evidence for the impact of military factors, such as deployment or rank, on IPV victimization was conflicting.

DISCUSSION

Prevalence rates varied widely, influenced by methodological variation among studies. The review highlighted the lack of research into male IPV victimization in the military and the relative absence of research into impact of IPV. It is recommended that future research disaggregates results by gender and considers the impact of IPV, in order that gender differences can be uncovered.

Prevalence of intimate partner violence perpetration among military populations: A systematic review and meta-analysis

Intimate partner violence (IPV) is a global health issue that impacts both civilian and military populations. Factors associated with military service may result in increased risk of IPV perpetration among Veterans and Active Duty military personnel. Six bibliographic databases were searched to identify studies that estimated the prevalence of IPV perpetration among military populations by sociodemographic and military characteristics. Where possible, random effect meta-analyses were conducted to determine pooled prevalence estimates. 42 studies were eligible for inclusion in this systematic review. 28 of these studies met the requirements for inclusion in subsequent meta-analyses. Among studies that measured past-year physical IPV perpetration, the pooled prevalence was higher among men compared to women (26% and 20% respectively). Among Veterans, there were consistently higher prevalences compared to Active Duty samples. Similarly, higher prevalences were found among studies in general military settings compared to clinical settings. Further research that considers the impact of the act(s) of IPV perpetration on the victims is needed. This, along with the use of a consistent measurement tools across studies will help to develop a stronger evidence base to inform prevention and management programs for all types of IPV perpetration among military personnel.

[Not Available]

Objectives:

Research suggests a high prevalence of problematic alcohol use among military personnel relative to civilians. Our primary objectives were to compare the prevalence, correlates, help-seeking behaviors, perceived need for care, and barriers to care for alcohol use disorders (AUDs) in the Canadian Armed Forces (CAF) and the Canadian general population (CGP).

Methods:

Data were from 2 nationally representative surveys collected by Statistics Canada: (1) the Canadian Community Health Survey on Mental Health collected in 2012 (N = 25,113; response rate = 68.9%) and (2) the Canadian Forces Mental Health Survey collected in 2013 (N = 8,161; response rate = 79.8%). Descriptive statistics and logistic regression were used to examine differences in outcomes of interest associated with AUDs in the CAF and CGP.

Results:

The prevalence of lifetime AUDs was significantly higher in the CAF (32.0%) than the CGP (20.3%; adjusted odds ratio [AOR] = 1.14, 95% confidence interval [CI, 1.02 to 1.27]) after adjustment for sociodemographic covariates. In contrast, the past-year prevalence of AUDs was significantly lower among CAF personnel (4.5%) than civilians (3.8%; AOR = 0.78, 95% CI [0.61 to 0.99]) after adjustment for sociodemographic covariates. Child abuse history and comorbid mental disorders were strongly associated with past-year AUDs in both populations. CAF personnel compared to the CGP were more likely to perceive a need for care (AOR = 4.15, 95% CI [2.56 to 6.72]) and engage in help-seeking behaviors (significant AORs ranged from 1.85 to 5.54). CAF personnel and civilians with past-year AUDs reported different barriers to care.

Conclusions:

Findings argue for the value of different approaches to address unmet need for AUD care in the CAF and CGP.

Evidence into action: implementing alcohol screening and brief interventions in the UK Armed Forces

Introduction

Alcohol-related harm continues to represent a major public health problem and previous evidence suggests that alcohol misuse within the UK Armed Forces is higher than in the general population. The aim was to introduce a population-level primary care intervention with an existing evidence base to identify and support Service Personnel whose drinking places them at greater risk of harm.

Implementation

Following successful piloting, the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) brief screening tool was introduced as part of routine dental inspections by Defence Primary Healthcare (DPHC) dentists. Alcohol brief intervention (ABI) advice and signposting to support services was offered to personnel identified as being at increased risk and recorded in the patient’s electronic health record.

Achievements to date

Patients attending DPHC Dental Centres are now routinely offered AUDIT-C with 74% (109 459) personnel screened in the first 12 months rising to over 276 000 at 24 months, representing the single largest use of AUDIT-C and ABIs in a military population to date.

Discussion

Introduction of AUDIT-C has seen Defence successfully deliver a whole population alcohol initiative, overcoming implementation barriers to demonstrate the flexibility of a dental workforce to deliver a public health intervention at scale and contributing towards promoting positive attitudes towards alcohol use. The initiative represents a first step towards the goal of a standardised alcohol screening and treatment pathway across DPHC while recognising that the Defence Medical Services are only one aspect of the broader public health approach required to tackle alcohol-related harm in Service Personnel.

UK military women: mental health, military service and occupational adjustment

Background

Recently, the UK Armed Forces have revised the ground close combat role to include women.

Aims

To assess the potential mental health impact of this initiative we examined gender differences in deployment patterns, work strain, occupational factors, mental health, alcohol use and help-seeking following operational deployment.

Methods

The study was a secondary analysis of self-report survey data; 8799 men (88%) and 1185 women (12%) provided data. A sub-sample (47%, n = 4659) provided data concerning post-deployment help-seeking. The latter consisted of 408 women (8.8%) and 4251 men (91%).

Results

With the exception of alcohol misuse, which was significantly lower for women, women reported significantly more common mental disorder symptoms, subjective depression and self-harm. Women were significantly more likely to seek help from healthcare providers. Men were significantly more likely to have deployed operationally and for longer cumulative periods. Subjective work strain, but not job control, was significantly lower for women whose military careers were significantly shorter. Post-traumatic stress disorder (PTSD) symptom intensity was similar to men.

Conclusions

With the exception of PTSD and alcohol misuse, UK military women experience more mental health-related problems than military men. This finding was not related to the more arduous aspects of military service as women served for shorter times, deployed less and for shorter cumulative periods and were less likely to report work-related stress.

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.

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.

Negative Alcohol and Tobacco Consumption Behaviors in an Australian Army Combat Brigade

Introduction

Western militaries have consumption rates of alcohol and tobacco which are higher than the associated civilian populations, and are concerned about the negative effects on health, wellbeing, and military performance that such high rates may have.

Materials and Methods

A survey questionnaire which collected nonidentifiable data was distributed to all accessible members of an Australian Army Combat Brigade over the annual induction training and prefield exercise period between January and March 2019. The survey was composed of personal and demographic questions, followed by questions concerning the personal consumption habits of alcohol and tobacco. 1,606 complete and valid surveys were returned, representing 55.3% of the Brigade’s posted strength. Ethical clearance for this project was provided by the Australian Defence Force Joint Health Command Low Risk Ethics Panel (18-012).

Results

Almost one quarter of the Combat Brigade exceeded the Australian daily risk guideline for alcohol consumption, and over three quarters exceeded the occasion risk guideline; with 6.1% of soldiers drinking alcohol daily. 24.3% identified as tobacco smokers, with 15.9% smoking daily. Smoking rates and volumes were higher when deployed on field training exercises and on international training and operational deployments; as was the consumption of roll-your-own cigarettes. Overall, the main determinants of the negative consumption behaviors were gender (male) and age (under 25).

Conclusions

This study confirmed that the members of an Australian Army Combat Brigade have higher negative health consumption behaviors concerning alcohol and tobacco than the general civilian population. The results also identified a cohort of Senior Non-Commissioned Officers and Warrant Officers (E5–E9) between the ages of 35 and 44 who had high negative consumption behaviors which could result in poor health outcomes. This could be a suitable cohort for a targeted campaign to reduce tobacco and alcohol consumption and to assist to make healthy life changes.

Alcohol use and sexual risk behaviors in the Armed Forces of the Democratic Republic of the Congo

BACKGROUND

Alcohol misuse is an important contributor to sexual acquisition and transmission of HIV in military communities. This cross-sectional study quantified the prevalence of probable problematic alcohol use among male service members in the Armed Forces of the Democratic Republic of the Congo (FARDC), identified associated factors, and investigated associations of alcohol misuse with risky sexual behaviors.

METHODS

Participants included 2549 active duty male soldiers ≥ 18 years old. Data were collected via computer-assisted personal-interview from October 2013-April 2014. The Alcohol Use Disorders Identification Test (AUDIT) was used to identify probable problematic alcohol use (AUDIT score ≥ 8) compared to no/low-risk alcohol use (AUDIT score ≤ 7). Bivariate logistic regressions were used to identify factors associated with probable problematic alcohol use. Several multivariable logistic regressions (adjusted for age, marital status, education level) were used to examine associations of probable problematic alcohol use with risky sexual behaviors. Tests were two sided; statistical significance was defined as p < 0.05.

RESULTS

Fifteen percent of men screened positive for probable problematic alcohol use. The odds of probable problematic alcohol use were elevated among men who were single and living with a partner (OR = 1.66; 95% CI = 1.24-2.21), ranked as a non-commissioned officer [NCO] (OR = 1.40; 95% CI = 1.10-1.77), and in the 30-39 and 40-49 age groups (OR 30-39 age group = 2.17; 95% CI = 1.56-3.02; OR 40-49 age group = 1.79; 95% CI = 1.26-2.55). Probable problematic alcohol use was associated with increased odds of having sex with a sex worker (SW), having multiple sexual partners, and participating in transactional sex (aOR sex with a SW = 2.36; 95% CI = 1.78-3.13; aOR multiple sexual partners = 2.08; 95% CI = 1.66-2.60; aOR transactional sex = 1.99; 95% CI = 1.59-2.50).

CONCLUSIONS

Results emphasize the need to address alcohol use in the FARDC and integrate alcohol abuse education into HIV prevention programs among male service members. Alcohol abuse prevention efforts should target men who are 30-49 years of age, unmarried, and ranked as a NCO. Messages and interventions to reduce alcohol misuse in relation to risky sexual behaviors are needed.

Alcohol use and its association with sexual risk behaviors in the Armed Forces of the Republic of the Congo

Background

Previous research has shown alcohol misuse amplifies the risk of acquiring sexually transmitted infections [STIs], including HIV, by increasing high risk sexual behaviors. Military populations are particularly vulnerable to both alcohol misuse and STIs due to the unique conditions of military service. This study estimated the prevalence of probable hazardous and harmful alcohol use and examined associations with transactional sex, sex with a sex worker, and multiple sexual partners among military personnel in the Armed Forces of the Republic of the Congo (FAC).

Methods

A secondary analysis of data collected from a 2014 seroprevalence and behavioral epidemiology risk survey was performed. Participants included 703 active duty male service members 18 years of age or older who reported ever having sex. Patterns of harmful and hazardous drinking were measured with the Alcohol Use Disorders Identification Test (AUDIT). Participants with an AUDIT score ≥ 8 (indicative of probable hazardous and harmful alcohol use, and possible alcohol dependence) were compared to those with an AUDIT score ≤ 7.

Results

A total of 15.8% received a score of 8 or higher on the AUDIT. These participants were more likely to be lower educated and of lower military rank. In separate multivariable models, an AUDIT score ≥ 8 was significantly associated with higher odds of sex with a commercial sex worker and having multiple sexual partners.

Conclusions

Study results emphasize the need to address patterns of harmful and hazardous alcohol use in the FAC and integrate alcohol misuse education into the HIV prevention program. The development of military-specific interventions to reduce alcohol-related risky sexual behaviors are also needed. Lastly, implementing policies such as restricting alcohol availability and sales on military bases, and adding warning labels to advertisements and containers may provide a more comprehensive response to reduce problematic alcohol use.

Living on the Edge: Emotional and Behavioral Problems in a Sample of Kosovar Veterans and Wives of Veterans 16 Years Postwar

Aim: This study aimed to explore the effects of war traumatic exposure on emotional and behavioral problems in a sample of Kosovar war veterans and the wives of veterans 16 years after the 1998-1999 war, as well as whether the level of education, income, well-being, and substance use are predictors for emotional and behavioral problems. Methods: Self-report data were obtained from 373 adults, 247 male war veterans (66.2% of the sample) and 126 wives of other male war veterans (33.8% of the sample). The sample was recruited from a list of war veterans provided by the Kosovar National Association of War Veterans. The mean age of participants was 45.42 [standard deviation (SD), 7.64] years. Measurements comprised a sociodemographic brief structured interview, the Well-Being Index (WHO-5), the Harvard Trauma Questionnaire, and the Adult Self Report (ASR). Logistic regression analysis was conducted to explore if the demographic variables were predictors for ASR general scales and subscales. Multivariate analysis of covariance was performed by adding as covariates the continuous variables pointed out in the logistic regression analysis as discriminating factors between the groups. Post hoc analyses were corrected, and we estimated partial η2 to measure the effect size. Results: The higher traumatic exposure during the war, the greater the tendency to have emotional problems and behavioral problems for both kinds of participants. The result showed that there were no differences on the prevalence of emotional and behavioral problems between the two groups, and both veterans and wives of veterans had no differences on seeking professional help for their emotional and behavioral problems. Wives of veterans living in rural areas showed higher scores on almost all ASR scales compared with those living in urban areas or even with those of veterans from urban and rural areas. Veterans with elementary education level had the highest scores compared with other groups. Veterans with poor well-being had the highest scores compared with other groups. Using Internalizing, Externalizing, and Total Problems as outcome variables and trauma exposure, smoking, drinking alcohol, and well-being as predictors, we found that the model was a significant predictor for both male and female participants on these three scales. Conclusion: The relationship found between the level of exposure to traumatic events and emotional and behavior problems, as well as the factors that moderated such relations, in war veterans and their wives, should help global mental health researchers address the contextual dimensions of this relationship and identify better ways to prevent and treat those problems.

Comparing the profiles of UK and Australian military veterans supported by national treatment programmes for post-traumatic stress disorder (PTSD)

Introduction

The aim of this study was to compare and contrast the profiles of military veterans seeking formal support for post-traumatic stress disorder (PTSD) in national treatment programmes in Australia and the UK to better understand the needs of this vulnerable population.

Methods

Data were extracted from 1926 participants in these treatment programmes. This consisted of 1230 from the UK who had accessed support between 2014 and early 2019, and 696 from Australia who had accessed support between 2014 and 2018. Comparison was made between a number of sociodemographic characteristics (age, sex and educational achievements), military factors (branch of military, time since leaving the military and whether participants were early service leavers or not) and health outcomes (PTSD, anger, alcohol misuse, anxiety and depression).

Results

Small differences were observed, with those in the UK cohort appearing to be younger, having lower educational achievement, being more likely to be ex-Army, having longer periods of enlistment in the military and taking longer to seek help. Further, minor differences were reported in health outcomes, with those in the UK cohort reporting more severe symptoms of PTSD, anger, anxiety and depression.

Conclusions

Overall, the observed differences between the cohorts were modest, suggesting that treatment-seeking veterans from the Australian and UK cohorts reported similar presentations. This provides evidence to support the establishment of international cohorts of treatment-seeking veterans to improve knowledge within this field.

Occupational stress in Remotely Piloted Aircraft System operators

BACKGROUND

Although there is currently little research data to support the contention, concerns have been raised about possible traumatic stressors inherent to Remotely Piloted Aircraft System (RPAS) operator roles. Factors such as exposure to visually traumatic events compounded by long working hours and blurred boundaries between military and civilian life have been cited as potential stressors. Robust research into the well-being of RPAS operators is scarce and mostly samples US personnel.

AIMS

To provide mental health and well-being data relating to UK RPAS operators.

METHODS

UK RPAS operators completed mental health questionnaires to assess levels of post-traumatic stress disorder (PTSD), anxiety and depression symptoms, alcohol use and occupational functioning. Respondents were also asked about work patterns.

RESULTS

Forty-one per cent of the sample reported potentially hazardous alcohol use. Ten per cent met psychiatric symptom criteria for moderate or severe anxiety, and 20% for moderate depressive symptoms. While there were no cases of probable PTSD, 30% of the sample reported sub-clinical PTSD symptoms likely to impair occupational functioning. Overall, 70% of the sample reported that psychological symptoms significantly impaired their functioning.

CONCLUSIONS

Compared to UK military sub-groups, RPAS operators were not at increased risk of mental health problems. However, a high proportion of the sample reported significant functional impairment, which has not been explored in other comparable studies. The most frequently highlighted work-related stressors were timing of RPAS work and operator shift patterns.

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.

Exploring patterns of alcohol misuse in treatment-seeking UK veterans: A cross-sectional study

AIMS

To explore patterns of alcohol misuse in a sample of treatment-seeking veterans compared to the UK Armed Forces personnel population and the general public. Furthermore, the present study investigated which variables were associated with alcohol misuse in this sample, and in particular what factors were associated with increased or decreased severity of alcohol misuse.

METHOD

The present study investigated alcohol misuse in treatment-seeking veterans and compared it with the UK Armed Forces and the general public. In addition, it explored associations between sociodemographic, physical health and mental health variables and alcohol misuse.

RESULTS

Results suggested that treatment-seeking veterans report different patterns of alcohol misuse compared to the UK Armed Forces and the general public. This group was more likely to report alcohol dependence and alcohol-related harm. They also reported higher levels of overall alcohol misuse than the general public. Mental health problems including PTSD, anxiety and depression, as well as anger, functional impairment and being single were all related to greater alcohol misuse. Being older and not in work were related to reduced alcohol misuse.

CONCLUSIONS

These findings add further weight to the importance of ensuring appropriate support is provided to personnel leaving the Armed Forces. Treatment-seeking veterans have specific patterns of alcohol-related needs that should be addressed. Knowing more about the common alcohol-related problems in this group can help inform and improve mental health interventions. Findings on related variables will help in identifying those individuals who may be at most risk of alcohol-related problems.

Fourteen-year trajectories of posttraumatic stress disorder (PTSD) symptoms in UK military personnel, and associated risk factors

The aim of this study was to examine trajectories of posttraumatic stress disorder (PTSD) symptoms over a 14-year period and the risk factors associated with each trajectory. 1885 UK military personnel provided information at four time points since 2002. The PTSD Check list-Civilian Version (PCL-C) was used at all time points. Growth mixture models (GMM) were estimated to examine whether individuals could be clustered into discrete groups with similar trajectories. Multinomial logistic regressions were carried out to investigate factors associated with class membership. The three-class GMM was the most parsimonious solution. This included 90.2% in the resilient class, 4.1% in the improving class and 5.7% in the deteriorating class. Both the deteriorating and improving classes were associated with childhood adversity (odds ratios (OR) 3.9 (95% CI 2.3, 6.7) and 3.3 (95% CI 2.1, 5.0) respectively) and antisocial behaviour (OR 2.8 (95% CI 1.9, 4.2) and 3.7 (95% CI 2.4, 5.8) respectively), alcohol misuse (OR 3.5 (95% CI 2.4, 5.1) and 3.3 (95% CI 2.1, 5.2) respectively) and longer time since leaving Service in comparison to the resilient group. Those in the youngest group and those in a combat role (OR 0.32, 95% CI 0.19, 0.54) were more likely to belong to the deteriorating class. 10% of the cohort had symptoms of PTSD; of those, up to half were symptomatic for most of the follow-up period. Those whose score improved did not reach the low scores of the resilient group. Younger age and combat role were associated with worse prognosis of PTSD.