Symptoms of post-traumatic stress disorder in Falklands veterans five years after the conflict

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

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

Plain language summary

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

Executive summary

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

Recognition and treatment of psychological disorders during military service in the UK armed forces: a study of war pensioners

PURPOSE

Little is known about the detection and treatment of psychological disorders arising during military service. We investigated whether personnel who developed disorders while serving in the UK armed forces came to the attention of medical services for these problems, received corresponding diagnoses, and were treated.

METHODS

For this retrospective record-based study 132 veterans in receipt of a war pension for psychological or physical problems received a lifetime diagnostic interview. Those with onsets of PTSD, depression, or alcohol abuse while in service were compared with those who never developed any condition or only developed it after discharge. Their medical records were inspected for contemporaneous contacts, diagnoses, and treatment.

RESULTS

PTSD and depression, but not alcohol abuse, were independently associated with mental health contacts while in service. The median time from PTSD onset to first contact was 1 month. Under half of personnel meeting criteria for these disorders received a corresponding diagnosis, and alcohol abuse was more likely to be recognised in the context of comorbid PTSD. PTSD was as well recognised in earlier as in later years covered by the study. Most personnel with disorders received treatment, and those treated were more likely to be medically downgraded or discharged.

CONCLUSIONS

War pensioners are more likely than not to have had their psychological problems acknowledged and treated while in service. The fact that these problems are still largely present 10 years later raises questions over the continuity of care associated with the transition to civilian life.

Trauma and victims: epidemiology of post-traumatic stress disorder

Scopo- Presentare una esaustivareviewdegli studi riguardanti l'epidemiologia del DPTS condotti nella popolazione generale, tra i soggetti a rischio, e, infine, tra gruppi clinicamente selezionati.Disegno- AttraversoExcepta Medica PsychiatryCD-ROM 1980-1993 (ottobre), utilizzando come parola chiave «Post-Traumatic Stress Disorder», sono stati identificati 1.057 articoli pubblicati nel periodo considerate Sono stati anche consultati altridata basedella letteratura medica (MEDLINE CD-ROM 1988-1993); è stata quindi operata una ricerca manuale su tutti i numeri delJournal of Traumatic Stress. Risultati- In totale, 135 lavori che hanno soddisfatto i criteri di inclusione prescelti sono stati inclusi nella review. I due terzi (n = 86, 64%) di queste ricerche sono state condotte negli USA. Solo 8 (6%) sono le indagini effettivamente realizzate nei paesi del Terzo Mondo. L'ampiezza del campione varia da un minimo di 11 soggetti, numero riscontrato in due studi, sino ad un massimo di 22.436, per un campione medio di 500 e mediano di 108. Per quanto attiene ai metodi di valutazione, in un terzo degli studi (n = 45, 33%), i ricercatori hanno impiegato un questionario (auto- o etero- somministrato). In un altro terzo delle ricerche elencate (n = 44, 33%) e stata somministrata un'intervista strutturata (la DIS, la SCID, o la SADS), mentre nei rimanenti studi la valutazione diagnostica si è basata o su una procedura clinica non strutturata, o sulla somministrazione di altri strumenti specifici dai quali è possibile inferire una diagnosi di DPTS (M-PTSD, IES, SCL-90-R,o pochi altri). In 77 studi (57%) i ricercatori hanno basato la loro valutazione sui criteri diagnostici propri del DSM-III, mentre in altri 55 (41%) su quelli del DSM-III-R. La prevalenza del DPTS e analizzata quindi separatamente per le diverse popolazioni studiate.Conclusioni- Nell'arco di soli 13 anni, a partire cioe dalla definizione di criteri diagnostici operazionali ben definiti per il DPTS, sono stati condotti numerosi studi volti ad indagare la prevalenza, i fattori di rischio, la storia naturale, il decorso e l' esito di questo disturbo tra campioni diversi di popolazioni a rischio; inoltre, anche il livello qualitativo di queste ricerche, per quanto attiene alia sofisticazione metodologica, si è accresciuto sensibilmente in un tempo tutto sommato breve. Molte aree, pero', restano tuttora inesplorate, ed inoltre appare imperativo avviare ricerche estensive tra le popolazioni dei paesi in via di sviluppo, maggiormente esposte a disastri naturali o provocati dall'uomo.

Mental health and health service use among post-national service veterans: results from the 2007 Adult Psychiatric Morbidity Survey of England

BACKGROUND

There is concern surrounding the psychological health and uptake of treatment services among veterans of the UK Armed Forces.

METHOD

Data from a cross-sectional, nationally representative sample were used to compare health outcomes and treatment seeking among 257 post-national service veterans aged 16-64 years and 504 age and sex frequency-matched non-veterans living in the community in England. Early leavers (<4 years service) were compared with longer serving veterans.

RESULTS

Male veterans reported more childhood adversity and were more likely to have experienced a major trauma in adulthood than non-veterans. There was no association between any measure of mental health and veteran status in males, except reporting more violent behaviours [adjusted odds ratio (aOR) 1.44, 95% confidence interval (CI) 1.01-2.06]. In females, a significant association was found between veteran status and ever having suicidal thoughts (aOR 2.82, 95% CI 1.13-7.03). No differences in treatment-seeking behaviour were identified between veterans and non-veterans with any mental disorder. Early service leavers were more likely to be heavy drinkers (aOR 4.16, 95% CI 1.08-16.00), to have had suicidal thoughts (aOR 2.37, 95% CI 1.21-4.66) and to have self-harmed (aOR 12.36, 95% CI 1.61-94.68) than longer serving veterans.

CONCLUSIONS

The findings of this study do not suggest that being a veteran is associated with adversity in terms of mental health, social disadvantage or reluctance to seek treatment compared with the general population. Some evidence implies that early service leavers may experience more mental health problems than longer-serving veterans.

A Good War? Exploring British veterans' moral evaluation of deployment

Historically, war trauma research has concentrated on the relationship between level of exposure and development of post-traumatic symptoms. More recently, it has been recognized that intra- and interpersonal differences can mediate how service personnel are affected by their experiences. This paper is a qualitative study exploring moral evaluations of 30 British male veterans towards their deployment in conflicts from WWII to the most recent Iraq War (2003-2009). Retrospective thematic analysis is used to explore moral evaluation and societal support. Four categories emerged based on veterans' moral evaluation of deployment: justifiable, implicitly justifiable, unclear, and unjustifiable. Analysis revealed broad differences between these groups. Veterans able to justify their experiences reported more positive aspects of both deployment and societal support than those unable to justify their deployment. These findings make clear the importance of future research exploring the interactions between civilians and service personnel, and the impact this has on mental health.

Falklands War veterans' perceptions of social support and the reconciliation of traumatic memories

The current paper focused on the role social support plays in the reconciliation of traumatic memories. Four currently serving, male Royal Marines ranging from 40-42 years participated in semi-structured one-to-one interviews that explored perceptions of social support. Using thematic analysis, comradeship was found to be important in terms of maintaining support networks. However, this resource was used to avoid the reconciliation of traumatic memories. Social support from family members was sought when veterans were reassured that relatives would understand their experiences, and could support reconciliation. The importance of positive societal reaction was also emphasized. The paper concludes by highlighting the potential for early life reconciliation of traumatic war memories through the creation of a meaningful personal narrative.

Work related post-traumatic stress as described by Jordanian emergency nurses

BACKGROUND

Although there is a growing interest in the consequences of work-related stress among healthcare professionals, most of the research has concentrated on western countries. Empirical studies of work related stress among health care workers from the Middle East have rarely been performed.

OBJECTIVES

The aim of the study was to identify causes of post-traumatic stress symptoms and their relationship with daily work stress exposure. This qualitative study was undertaken using hermeneutic phenomenology and involved a representative group of 25 nurses from Jordan.

RESULTS

Work related stress symptoms were associated with poor social support. The findings stress the necessity for staff to support each other, for supervisors to support and counsel their staff and also for the management to promote and encourage support. Jordanian nurses are seriously at risk from high levels of stress symptoms.

CONCLUSIONS

The results of this study will enable nurses to better identify and handle stressful situations in the early stages and in a timely fashion. It will help administrators, teachers and researchers to plan strategies (interventions) in the hospitals, curriculum and in knowledge needed to promote the quality of life for nurses.

'Goodbye and good luck': the mental health needs and treatment experiences of British ex-service personnel

BACKGROUND

Little is known about the psychological health or treatment experiences of those who have left the British armed forces.

AIMS

To describe the frequency and associations of common mental disorders and help-seeking behaviours in a representative sample of UK veterans at high risk of mental health problems.

METHOD

A cross-sectional telephone survey of 496 'vulnerable' ex-service personnel selected from an existing epidemiological military cohort.

RESULTS

The response rate was 64%; 44% of these had a psychiatric diagnosis, most commonly depression. Those with a diagnosis were more likely to be of lower rank and divorced or separated. Just over half of those with self-reported mental health problems were currently seeking help, most from their general practitioners. Most help-seekers received treatment, usually medication; 28% were in touch with a service charity and 4% were receiving cognitive-behavioural therapy.

CONCLUSIONS

Depression is more common than post-traumatic stress disorder in UK ex-service personnel. Only about half of those who have a diagnosis are seeking help currently, and few see specialists.

Guilt, shame and need for a container: a study of post-traumatic stress among ambulance personnel

Post-traumatic stress symptoms among ambulance personnel are regarded as a natural behaviour and reaction to working with the severely injured, suicides, injured children and dead people. The findings show that post-traumatic stress symptoms, guilt, shame and self-reproach are common after duty-related traumatic events. To handle these overwhelming feelings it is necessary to talk about them with fellow workers, friends or family members. By using another person as a container it is possible to internalise the traumatic experience. Poor and un-emphatic behaviour towards a patient and their relatives can have its origin in untreated traumatic experiences. Personnel in ambulance organisations who perform defusing, debriefing and counselling have to be informed of the importance that the roll of guilt and shame may play in the developing of post-traumatic stress symptoms.

A study into commanders' understanding of, and attitudes to, stress and stress-related problems

OBJECTIVES

To undertake a tri-Service questionnaire survey to examine the commanders' understanding of, and attitudes to, stress and stress-related problems.

METHODS

A questionnaire was designed to elicit information on: Personal experience of stress and stress-related problems; Stress education; Pre-deployments briefings; and Post-incident stress debriefing. A total of 9,020 questionnaires were distributed between the three Services based on their proportional manning contribution to the Armed Forces as a whole. The population sampled ranged in rank from Corporal/Leading Rate up to, and including, Colonel/Captain RN/Group Captain (ranks below Leading Rate/ Corporal were excluded because of their lack of command experience). The overall response rate was 55.8%. The study was carried out between September and December 2001 (i.e. pre-OP TELIC).

RESULTS

Chronic work-based stressors were seen as most stressful when compared with family and health stressors. Most respondents accepted that stress and stress-related problems exist, but were reluctant to disclose their own stress-related problems or seek help for fear that it might be detrimental both personally and professionally. There was found to be little support from peers or commanders. Little stress training was provided during recruit training, there were gaps in pre-deployment briefings and little in the way of post-deployment stress support.

CONCLUSIONS

Some of the more negative findings could have implications in terms of seeking help for stress-related problems at an early stage, which is counter-productive to the military's genuine attempts to foster the psychological welfare of its employees. Some concerns could be alleviated by better and more timely stress education, preferably early on in a commander's career, so that positive attitudes to stress and stress-related problems can be formed and any negative attitudes changed, thereby bringing about a change in organisational culture in relation to stress. Some of the study's concerns were addressed by the Operational Health Strategic Surveillance Committee which advised on operational health aspects of OP TELIC.

Posttraumatic stress disorder (PTSD) in the Armed Forces: health economic considerations

This paper addresses the use of health economics in relation to posttraumatic stress disorder (PTSD) in the Armed Forces, with a view to assessing the feasibility of carrying out future evaluative studies. Although psychological and pharmacological interventions can be used to treat PTSD, no economic evaluations are known to exist. There is an economic burden associated with PTSD, and treatments require the use of scarce resources. Health economics provides tools (including cost-effectiveness, cost-benefit, and cost-utility analyses) to ascertain the relative efficiency of different treatment options. The paper concludes that the quality of life and resource consequences of PTSD require a better understanding of the economics of the disorder and the alternative ways to treat it.

Living in danger: the impact of chronic traumatization and the traumatic context on posttraumatic stress disorder

In this article on the effects of chronic traumatization, research is reviewed regarding the association between chronicity of traumatization and posttraumatic stress disorder (PTSD) symptomatology. The contribution of the broader traumatic context to PTSD symptomatology is also examined. This review focuses on three populations: combat veterans, child sexual abuse survivors, and survivors of domestic violence. The challenges of defining chronicity of a traumatic event and traumatic context are addressed. Finally, suggestions for future directions are provided.

Flashbacks and post-traumatic stress disorder: the genesis of a 20th-century diagnosis

BACKGROUND

It has been argued that post-traumatic stress disorder (PTSD) is a timeless condition, which existed before it was codified in modern diagnostic classifications but was described by different names such as 'railway spine' and 'shellshock'. Others have suggested that PTSD is a novel presentation that has resulted from a modern interaction between trauma and culture.

AIMS

To test whether one core symptom of PTSD, the flashback, has altered in prevalence over time in soldiers subjected to the intense stress of combat.

METHOD

Random selections were made of UK servicemen who had fought in wars from 1854 onwards and who had been awarded war pensions for post-combat disorders. These were studied to evaluate the incidence of flashbacks in defined, at-risk populations.

RESULTS

The incidence of flashbacks was significantly greater in the most recent cohort, veterans of the 1991 Persian Gulf War; flashbacks were conspicuous by their absence in ex-servicemen from the Boer War and the First and Second World Wars.

CONCLUSIONS

Although this study raises questions about changing interpretations of post-traumatic illness, it supports the hypothesis that some of the characteristics of PTSD are culture-bound. Earlier conflicts showed a greater emphasis on somatic symptoms.

Post-traumatic stress among Swedish ambulance personnel

OBJECTIVE

Emergency workers, including ambulance personnel, must cope with a variety of duty related stressors including traumatic incident exposures. Little is known about the variables that might be associated with post-traumatic stress symptom in high risk occupational groups such as ambulance personnel. This study investigated the prevalence of post-traumatic stress disorder among Swedish ambulance personnel.

METHODS

To estimate the prevalence of trauma related disorders, a representative group of 362 ambulance personal from the county of Västra Götaland in Sweden was surveyed through use of a Swedish version of Antonovsky's 13-item short version of Sense of Coherence Scale, to measure reactions to traumatic events two instruments were used, Impact of Event Scale (IES-15) and the Post Traumatic Symptom Scale (PTSS-10). A total of 223 of the ambulance personnel reported that they had had experience of what they described as traumatic situations.

RESULTS

Of those who reported a traumatic situation 15.2% scored 31 or more on the IES-15 sub scale. Scores over 31 indicate a stress reaction with certain likelihood of post-traumatic disorder. On the PTSS-10 subscale 12.1% scored 5 or more, which indicates a relative strong reaction. The study indicates that lower sense of coherence predicts post-traumatic stress. Other predictors for the extent of traumatic stress were longer job experience, age, physical and psychological workload.

CONCLUSIONS

The high prevalence of post-traumatic stress disorder symptoms in ambulance personnel indicates an inability to cope with stress in daily work. The strong relation between post-traumatic stress and Sense of Coherence Scale may be useful in predicting vulnerability for post-traumatic symptoms among recently employed ambulance service personnel. To prevent or reduce the upcoming of post-traumatic stress disorder symptoms it must be possible to take leave of absence, or for a longer or shorter time be transferred to non-emergency duties. This study presents a better understanding between post-traumatic stress and underlying factors among ambulance personnel.

Posttraumatic Stress Disorder three years after the siege of Sarajevo

The goals of this study were to estimate the lifetime prevalence of traumatic events, the current prevalence of Posttraumatic Stress Disorder (PTSD), and the connection between the kinds of traumatic events experienced and the probability of developing PTSD in three study samples in Sarajevo, Bosnia-Herzegovina, three years after the end of the war. A total of 311 people surviving the siege of Sarajevo were assessed with the Checklist for War Related Experiences (CWE) and an adapted version of the Posttraumatic Diagnostic Scale (PDS). The study groups consisted of a randomly selected residents sample (n = 98), a group of individuals in psychological treatment (n = 114), and a group in medical treatment (n = 99). Each individual survived an average of 24 traumatic events. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV; American Psychiatric Association, 1994) criteria, 18.6% of individuals in the residents sample, 32.7% of those in medical treatment, and 38.6% of those in psychological treatment developed PTSD.

Medical help-seeking by motor vehicle accident claimants

The assessment of general psychiatric damages in personal injury cases is partly determined by evidence that the claimant has attempted to mitigate their losses by seeking medical help. However, there is no evidence that seeking medical help for a psychiatric injury is typical behaviour. The general practice consultation behaviour of 100 claimants with chronic physical and psychiatric injury with an onset at the time of a motor vehicle accident, was assessed over a 12-month period after the injury. GP consultations for physical and psychiatric symptoms were compared. At 12 months after the accident 53 (95% CI 42.7, 63.3) had consulted their GP with psychiatric symptoms and 94 (95% CI 88.8, 99.2) had consulted their GP with physical symptoms. Neither the sex, age or a pre-accident history of help-seeking for psychological symptoms was significantly predictive of post-accident help seeking for psychiatric injury. The results from this study provide information about the weight that should be given to medical help-seeking as a factor in assessing the value of claims for general psychiatric damages in personal injury cases.

Hearts and minds: suicide among United States combat troops in Vietnam, 1957-1973

The literature on suicides among military personnel in a combat zone remains anecdotal. Although one finds literary and journalistic accounts of the problem, it has not been systematically analyzed. This paper will examine suicides among American combat troops during their tour of duty in Vietnam. Utilizing statistical data from the Southeast Asia Combat Area Casualties Database (SACACD), the authors will survey its epidemiology among U.S. ground troops in Vietnam from 1957 to 1973. The results suggest that certain types of combat troops were significantly more likely than others to commit suicide. These findings not only provide important predictors for military health professionals in the assessment of suicide risk, they also raise disturbing questions about the nature of organized armed conflict.

Psychiatric morbidity in Australian veterans of the United Nations peacekeeping force in Somalia

OBJECTIVE

Since World War II, an increasing number of soldiers have been deployed in United Nations (UN) peacekeeping forces. However, little is known about the psychiatric impact of such deployments. The present study investigated the nature, prevalence, aetiology and natural history of psychiatric morbidity in Australian veterans of the United Nations peacekeeping force in Somalia.

METHOD

Fifteen months after their return from Somalia, 117 Somalian veterans completed the 28-item version of the General Health Questionnaire (GHQ-28), the Impact of Events Scale (IES), the Combat Exposure Scale (CES), and a checklist of posttraumatic stress disorder symptoms, completed by veterans 12 months previously as part of an evaluation by the Department of Defence. Seventy-seven non-veteran controls also completed the GHQ-28.

RESULTS

Veterans scored significantly higher on the GHQ-28 than controls. Twenty-four-point-eight per cent (24.8%) of veterans were GHQ cases (using 4/5 as a cut-off point) compared to 13.0% of controls. Psychiatric morbidity in veterans was associated with combat exposure and a past psychiatric history. Levels of morbidity reduced over time, although they remained substantial at 15 months following soldiers' return to Australia, with posttraumatic stress disorder symptoms being reported by approximately 20% of veterans.

CONCLUSIONS

At least one-fifth of Australian soldiers who served in Somalia had significant levels of psychiatric morbidity 15 months following their return. This was almost twice that of their non-veteran peers. Risk factors for the development of psychiatric morbidity included combat exposure and past psychiatric history. Levels of psychiatric morbidity were much higher than those reported in previous studies on UN soldiers.

POST-TRAUMATIC STRESS DISORDER IN POLY-TRAUMA CASES

Six hundred and one patients, who sustained injuries in militant activities, admitted during a 7 month period to a zonal referral hospital were studied. The majority, 54.6% from the Armed Forces and 38.8% from the para-military forces, were in the age group of 22-53 years. There were 40 (6.7%) civilian casualties. These were in the age group of 20-45 years. A large number (75.7%) of the casualties manifested with post-traumatic stress symptoms. 24.3% of them were rated as post-traumatic stress disorder. Six months follow-up revealed persistence of post-traumatic stress disorder in 17.1% of the cases. By one year, 42.1% who responded to the follow-up letters had persistence of post-traumatic stress disorder in 4.95%. Early recognition of this psychic trauma and preventive strategies are discussed.

Behavioural treatments in post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is increasingly becoming recognised as a serious mental health problem (Department of Health, 1991). Psychological treatments for PTSD remain in their infancy, though limited research has demonstrated the efficacy of behavioural and cognitive-behavioural interventions.

Development and validation of the computerized clinician administered post-traumatic stress disorder scale-1-revised

A computer administered version of the clinician administered post-traumatic stress disorder (PTSD) scale-1 was developed to assess PTSD in subjects presenting with psychological symptoms following exposure to a traumatic event. Both forms were administered to 40 subjects who met the Diagnostic and Statistical Manual, third edition, revised (DSM-III-R) criteria for exposure to a significantly traumatic stressor. Inter-observer reliability was demonstrated with a kappa statistic of 0.90. The computer version had a sensitivity of 0.95 and a specificity 0.95. A correlation of 0.95 was found between the two versions and the mean score difference was non-significant. The computer form demonstrated adequate internal reliability and test-retest reliability. Overall results suggest the computer version is a valid and reliable measure of PTSD.

Psychological sequelae following the Gulf War. Factors associated with subsequent morbidity and the effectiveness of psychological debriefing

BACKGROUND

The aim was to study the effect of brief counselling and psychological debriefing following a trauma on subsequent morbidity.

METHOD

We investigated psychological morbidity in 62 British soldiers whose duties included the handling and identification of dead bodies of allied and enemy soldiers during the Gulf War. Of these soldiers, 69% received a psychological debriefing on completion of their duties. The subjects completed by post a demographic questionnaire, the General Health Questionnaire (GHQ-28) and the Impact of Events Scale.

RESULTS

After nine months 50% had evidence of some psychological disturbance suggestive of posttraumatic stress disorder (PTSD); 18% had sought professional help; 26% reported relationship difficulties. Neither prior training nor the psychological intervention appeared to make any difference to subsequent psychiatric morbidity. Morbidity at nine months was more likely in those with a history of psychological problems and those who believed their lives had been in danger in the Gulf.

CONCLUSIONS

These findings show that a psychological debriefing following a series of traumatic events or experiences does not appear to reduce subsequent psychiatric morbidity and highlights the need for further research in military and civilian settings.

After the war in Nicaragua: a psychosocial study of war wounded ex-combatants

Despite 150 wars in the Third World since 1945, there have been virtually no psychosocial studies of war wounded ex-combatants. This community study of 72 such men, on average 4.9 years post-injury, had both quantitative (General Health Questionnaire [GHQ] and clinical interview) and qualitative (personal narrative) components. Most men were coping adaptively. However their overall GHQ scores were significantly higher than an ex-combatant control group, suggesting relative psychological vulnerability (P = 0.001). 13 (18 per cent) had post-traumatic stress disorder (PTSD) though in only three was this clinically significant, two of whom were aggressive alcoholics. Social dysfunction was a better indicator of the minority who needed psychological help than a diagnosis of PTSD. The one in three with a severe physical disability were not at greater risk than the rest of the group. Personal narratives illuminated the ways subjects had registered and responded to their war experiences. Identification with the social ideals being defended by the war effort had been psychologically bolstering. Ten severely disabled ex-Contra guerrillas, who had fought on the other side, were also interviewed. The availability of appropriate training/work, and thus the economic fortunes of the whole society, are likely to be major determinants of long-term psychosocial outcomes. Six illustrative personal histories are appended.