Is peacekeeping peaceful? A systematic review

Lifetime Prevalence and Comorbidity of Mental Disorders in the Two-wave 2002-2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS): Prévalence et Comorbidité de Durée de vie Des Troubles Mentaux Dans l'Enquête de Suivi Sur la Santé Mentale Auprès des Membres des Forces Armées Canadiennes et Des ex-Militaires (ESSMFACM) en Deux Cycles de 2002 à 2018

OBJECTIVE

The current study used the Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS) to (1) examine the incidence and prevalence of mental disorders and (2) estimate the comorbidity of mental disorders over the follow-up period.

METHOD

The CAFVMHS (2018) is a longitudinal study with two time points of assessment. The sample is comprised of 2,941 Canadian Forces members and veterans who participated in the 2002 Canadian Community Health Survey: Canadian Forces Supplement. The World Health Organization Composite International Diagnostic Interview (WHO-CIDI) was utilized to diagnose Diagnostic and Statistical Manual-IV post-traumatic stress disorder (PTSD), major depressive episode (MDE), generalized anxiety disorder, social anxiety disorder (SAD), and alcohol abuse and dependence. Self-report health professional diagnoses were assessed for attention deficit hyperactivity disorder (ADHD), mania, obsessive compulsive disorder (OCD), and personality disorder. We established weighted prevalence of mental disorders and examined the association between mental disorders using logistic regression.

RESULTS

In 2018, lifetime prevalence of any WHO-CIDI-based or self-reported mental disorder was 58.1%. Lifetime prevalence of any mood or anxiety disorder or PTSD was 54.0% in 2018. MDE (39.9%), SAD (25.7%), and PTSD (21.4%) were the most common mental disorders. There was a substantial increase in new onset or recurrence/persistence of mental disorders between the two measurement points (16-year assessment gap); 2002-2018 period prevalences were 43.5% for mood and anxiety disorder and 16.8% for alcohol abuse or dependence. The prevalence of self-reported ADHD, OCD, any personality disorder, and mania were 3.3%, 3.0%, 0.8%, and 0.8%, respectively. Comorbidity between mental disorders increased over the follow-up.

CONCLUSIONS

This study demonstrates a high burden of mental disorders among a large Canadian military and veteran cohort. These findings underscore the importance of prevention and intervention strategies to reduce the burden of mental disorders and alcohol use disorders in these populations.

Caring for Coronavirus Healthcare Workers: Lessons Learned From Long-Term Monitoring of Military Peacekeepers

BACKGROUND

The current outbreak of the coronavirus disease (COVID-19) is of unprecedented proportions in several regards. Recent reports suggest that many frontline healthcare workers (HCWs) suffer from mental health problems, including posttraumatic stress symptoms (PTSS). Previous studies have identified several key factors associated with short-term PTSS in pandemic HCWs, yet limited data is available on factors associated with long-term PTSS. Understanding the psychological impact of the pandemic on HCWs is important in planning for future outbreaks of emerging infectious diseases. In the current study, we look to findings from a highly relevant subsection of the trauma field, the military domain.

OBJECTIVE

Pandemic HCWs and military peacekeepers may experience similar stressors in the line of duty. This study investigated whether factors linked to short-term PTSS in pandemic HCWs were also associated with long-term PTSS in military peacekeepers.

MATERIALS AND METHODS

Peacekeepers who reported pandemic-relevant stressors during deployment to a UN peacekeeping mission were included in the study (N = 1,627). PTSS was self-reported using the Posttraumatic Stress Disorder Checklist - Military Version. Descriptive instruments were used to assess possible factors associated with PTSS. A multiple linear regression analysis was performed to explore associations between these factors and PTSS.

RESULTS

Our model accounted for 50% of the variance in PTSS, F(1503,11) = 139.00, p < 0.001. Age, relationship and employment status, preparedness, working environment, social support after deployment, barriers to disclose, recognition, and loneliness were all significantly associated with PTSS on average 30 years after deployment. The most important risk factors of long-term PTSS were personal barriers to disclose one's experiences and current unemployment.

CONCLUSION

Several factors linked to short-term PTSS in pandemic HCWs were associated with long-term PTSS in peacekeepers. We discuss how these findings may be used to prevent long-term PTSS in HCWs involved in the current COVID-19 outbreak.

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.

Deployment-Related Traumatic Events and Suicidal Behaviours in a Nationally Representative Sample of Canadian Armed Forces Personnel

OBJECTIVE

Worldwide, there has been substantial controversy with respect to whether military deployment is a risk factor for suicidal behaviour. The present study examined the relationship between lifetime exposure to deployment and deployment-related traumatic events (DRTEs) and past-year suicidal ideation (SI), suicidal plans (SP), and suicidal attempts (SA).

METHOD

Data were analysed from the 2013 Canadian Forces Mental Health Survey (8161 respondents; response rate, 79.8%; aged 18-60 years). A total of 12 individual items assessed exposure to DRTEs (e.g., combat, witnessing human atrocities, feeling responsible for the death of Canadian or ally personnel, knowing someone who was injured or killed). We examined each individual DRTE type as well as the number of types of DRTEs in relation to suicidal behaviour.

RESULTS

Lifetime deployment was not significantly associated with suicidal behaviour. In models adjusted for sociodemographic variables, most of the individual DRTE items and the DRTE count variable were significantly associated with suicidal behaviours (adjusted odds ratio ranged between 1.10 and 5.32). When further adjusting for child abuse exposure, these associations were minimally attenuated, and some became nonsignificant. In models adjusting for mental disorders and child abuse, most DRTEs and number of types of DRTEs became nonsignificant in relation to SI, SP, and SA.

CONCLUSIONS

Active military personnel exposed to increasing number of DRTEs are at increased risk for SI, SP, and SA. However, most of the association between DRTEs and suicidal behaviour is accounted for by child abuse exposure and mental disorders.

Comparing post-deployment mental health services utilization in soldiers deployed to Balkan, Iraq and Afghanistan

OBJECTIVE

Insight on how different missions have impacted rates of mental health service (MHS) utilization is unexplored. We compared postdeployment MHS utilization in a national cohort of first-time deployed to missions in Balkan, Iraq, and Afghanistan respectively.

METHODS

A prospective national cohort study of 13 246 first-time deployed in the period 1996 through 2012 to missions in Balkan area, Iraq, or Afghanistan respectively. Soldiers 'MHS utilization was also compared with a 5:1 sex-, age-, and calendar year-matched never-deployed background population. Postdeployment utilization of MHS was retrieved from national coverage registers. Using Cox survival analyses, participants were followed and compared with regard to receiving three different types of psychiatric services: (i) admission to psychiatric hospital, (ii) psychiatric outpatient contact, and (iii) prescriptions of psychotropics.

RESULTS

Utilizing of psychiatric outpatient services and psychotropics was significantly higher in first-time deployed to Iraq and Afghanistan compared with deployed to Balkan. However, the rate of postdeployment admission to psychiatric hospital did not differ between missions. Postdeployment rates of psychiatric admission and psychiatric outpatient treatment were significantly higher in Afghanistan-deployed personnel compared with the background population.

CONCLUSIONS

Utilization of MHS differed significantly between mission areas and was highest after the latest mission to Afghanistan.

Peacekeepers deserve more mental health research and care

SUMMARY

United Nations peacekeeping personnel face numerous stressors due to their challenging deployments. Past studies have had inconsistent results regarding whether or not their deployment experience affects their mental health outcomes. Further studies are required to ascertain the associations between their outcomes and factors before, during and after their peacekeeping missions.

DECLARATIONS OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

International military operations and mental health--A review

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS AND CONCLUSIONS

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

The long-term mental health impact of peacekeeping: prevalence and predictors of psychiatric disorder

BACKGROUND

The mental health outcomes of military personnel deployed on peacekeeping missions have been relatively neglected in the military mental health literature.

AIMS

To assess the mental health impacts of peacekeeping deployments.

METHOD

In total, 1025 Australian peacekeepers were assessed for current and lifetime psychiatric diagnoses, service history and exposure to potentially traumatic events (PTEs). A matched Australian community sample was used as a comparator. Univariate and regression analyses were conducted to explore predictors of psychiatric diagnosis.

RESULTS

Peacekeepers had significantly higher 12-month prevalence of post-traumatic stress disorder (16.8%), major depressive episode (7%), generalised anxiety disorder (4.7%), alcohol misuse (12%), alcohol dependence (11.3%) and suicidal ideation (10.7%) when compared with the civilian comparator. The presence of these psychiatric disorders was most strongly and consistently associated with exposure to PTEs.

CONCLUSIONS

Veteran peacekeepers had significant levels of psychiatric morbidity. Their needs, alongside those of combat veterans, should be recognised within military mental health initiatives.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.

'Post-deployment appraisal' and the relationship with stress and psychological health in Australian veterans

PURPOSE

Understanding how veterans appraise their post-deployment experiences could provide insight into better assisting their deployment transitions. We aimed to assess the factor structure of positive and negative post-deployment appraisals in Australian veterans and to examine the resultant factors in their relationship with military stress and psychological health.

METHOD

Questions capturing post-deployment attitudes were developed by the researchers in collaboration with veterans. The questions were administered to 1938 veterans and the results factor analysed. The relationships between post-deployment appraisal, military stress and psychological health were examined using Structural Equation Modelling.

RESULTS

A three-factor solution was found for the post-deployment appraisal questions; representing personal development, lack of recognition, and appreciation of life and country. Military stress was associated with the three factors and psychological health. The three factors were weakly to moderately associated with psychological health. Mediation between military stress and psychological health by any post-deployment appraisal factor was minimal.

CONCLUSIONS

Post-deployment appraisal measures three important attitudes and concerns of veterans after deployment. Military stress is associated with the post-deployment appraisal factors. However, the factors did not mediate the relationship between military stress and psychological health. These factors provide insight into how veterans appraise their complex array of post-deployment experiences, and may provide useful in regard to transitions and integration into civilian life.

The reappraisal of benzodiazepines in the treatment of anxiety and related disorders

Benzodiazepines (BDZs) continue to be shrouded in controversy, mainly because of dependence associated with their long-term use and some of their side effects. Despite treatment recommendations favoring newer antidepressants, BDZs are still commonly prescribed for anxiety and related disorders. Recent studies have demonstrated that long-term use of BDZs for these conditions can be effective and safe and that BDZs can be combined with psychological therapy and antidepressants to produce optimal outcomes. Such findings, along with a failure to convincingly demonstrate the overall superiority of alternative pharmacotherapy for anxiety and related disorders, have given an impetus to a reconsideration of the role of BDZs. This article reviews BDZs and other pharmacotherapy options for anxiety and related disorders and suggests that treatment guidelines should acknowledge that BDZs can be used as first-line, long-term pharmacological treatment for panic disorder, generalized anxiety disorder and social anxiety disorder.

Adverse childhood experiences in relation to mood and anxiety disorders in a population-based sample of active military personnel

BACKGROUND

Although it has been posited that exposure to adverse childhood experiences (ACEs) increases vulnerability to deployment stress, previous literature in this area has demonstrated conflicting results. Using a cross-sectional population-based sample of active military personnel, the present study examined the relationship between ACEs, deployment related stressors and mood and anxiety disorders.

METHOD

Data were analyzed from the 2002 Canadian Community Health Survey-Canadian Forces Supplement (CCHS-CFS; n = 8340, age 18-54 years, response rate 81%). The following ACEs were self-reported retrospectively: childhood physical abuse, childhood sexual abuse, economic deprivation, exposure to domestic violence, parental divorce/separation, parental substance abuse problems, hospitalization as a child, and apprehension by a child protection service. DSM-IV mood and anxiety disorders [major depressive disorder, post-traumatic stress disorder (PTSD), generalized anxiety disorder (GAD), panic attacks/disorder and social phobia] were assessed using the composite international diagnostic interview (CIDI).

RESULTS

Even after adjusting for the effects of deployment-related traumatic exposures (DRTEs), exposure to ACEs was significantly associated with past-year mood or anxiety disorder among men [adjusted odds ratio (aOR) 1.34, 99% confidence interval (CI) 1.03-1.73, p < 0.01] and women [aOR 1.37, 99% CI 1.00-1.89, p = 0.01]. Participants exposed to both ACEs and DRTEs had the highest prevalence of past-year mood or anxiety disorder in comparison to those who were exposed to either ACEs alone, DRTEs alone, or no exposure.

CONCLUSIONS

ACEs are associated with several mood and anxiety disorders among active military personnel. Intervention strategies to prevent mental health problems should consider the utility of targeting soldiers with exposure to ACEs.

Traumatic events, other operational stressors and physical and mental health reported by Australian Defence Force personnel following peacekeeping and war-like deployments

BACKGROUND

The association between stressful events on warlike deployments and subsequent mental health problems has been established. Less is known about the effects of stressful events on peacekeeping deployments.

METHODS

Two cross sectional studies of the Australian Defence Force were used to contrast the prevalence of exposures reported by a group deployed on a peacekeeping operation (Bougainville, n = 1704) and those reported by a group deployed on operations which included warlike and non-warlike exposures (East Timor, n = 1333). A principal components analysis was used to identify groupings of non-traumatic exposures on deployment. Multiple regression models were used to assess the association between self-reported objective and subjective exposures, stressors on deployment and subsequent physical and mental health outcomes.

RESULTS

The principal components analysis produced four groups of non-traumatic stressors which were consistent between the peacekeeping and more warlike deployments. These were labelled 'separation', 'different culture', 'other people' and 'work frustration'. Higher levels of traumatic and non-traumatic exposures were reported by veterans of East Timor compared to Bougainville. Higher levels of subjective traumatic exposures were associated with increased rates of PTSD in East Timor veterans and more physical and psychological health symptoms in both deployed groups. In Bougainville and East Timor veterans some non-traumatic deployment stressors were also associated with worse health outcomes.

CONCLUSION

Strategies to best prepare, identify and treat those exposed to traumatic events and other stressors on deployment should be considered for Defence personnel deployed on both warlike and peacekeeping operations.

Exploring the relationship between underlying dimensions of posttraumatic stress disorder and depression in a national, trauma-exposed military sample

BACKGROUND

Posttraumatic stress disorder (PTSD) and depression are highly comorbid and intercorrelated. Yet little research has examined the underlying processes explaining their interrelationship.

METHOD

In the present survey study, the investigators assessed the combined symptom structure of PTSD and depression symptoms, to examine shared, underlying psychopathological processes. Participants included 740 Canadian military veterans from a national, epidemiological survey, previously deployed on peacekeeping missions and administered the PTSD Checklist and Center for Epidemiological Studies-Depression Scale (CES-D).

RESULTS

An eight-factor PTSD/depression model fit adequately. In analyses validating the structure, PTSD's dysphoria factor was more related to depressive affect than to several other PTSD and depression factors. Somatic problems were more related to dysphoria than to other PTSD factors.

LIMITATIONS

Only military veterans were sampled, and without the use of structured diagnostic interviews.

CONCLUSIONS

Results highlight a set of interrelationships that PTSD's dysphoria factor shares with specific depression factors, shedding light on the underlying psychopathology of PTSD that emphasizes dysphoric mood.

Suicide prevention in military organizations

Suicide is an important public health problem in the demographic group that forms the bulk of military populations, namely young and middle-aged men. Suicide in the military also has special significance: certain aspects of military service can lead to serious mental disorders that increase the risk of suicidal behaviour. Moreover, military organizations have control over a broad range of factors (notably the direct delivery of mental health care) that could mitigate suicide risk. This article will review the literature on suicide risk in military organizations to answer the important question: Are military personnel at increased risk for suicide? Next, Mann et al.'s (2005) model for specific suicide preventive interventions in civilian settings will be reviewed and then expanded, with an emphasis on identifying special opportunities for suicide prevention in military organizations, including: 1) organizational interventions to mitigate work stress; 2) selection, resilience training, and risk factor reduction; 3) interventions to overcome barriers to care; and 4) systematic quality improvement efforts in mental health care. Finally, the evidence behind comprehensive suicide prevention programmes will be reviewed, with a special focus on the US Air Force's benchmark programme.