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

Meaning(s) of transition(s) from military to civilian life at the intersection with mental health: implications for clinical settings

The experiences of military personnel moving into civilian life can be varied for the individual, families and communities. This paper aims to shed light on the various meanings of the multiple and "nested" transitions of military personnel to civilian life in the context of attending a mental health service in the UK. This was achieved through secondary analysis of semi-structured interviews with veterans who were engaging with a mental health service in the UK and a further interview with the mental health service lead. A thematic analysis was employed based on a descriptive phenomenological approach. Results indicate that an appropriate support infrastructure needs to be put in place for veterans prior to, during and after the transition to civilian life. The support appropriateness includes themes specific to connectedness to others, support service accessibility, mental health professionals' military culture awareness and mental health stigma. Although the findings suggest that community services need an awareness of veterans' specific needs, many of the themes are similar to those of the general population. Therefore, the need for an integrated healthcare system is essential in the transition of military service personnel to civilian life. Drawing on international evidence as well as the current findings, implications for policy and practice are highlighted throughout.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Recruiting Military Veterans into Alcohol Misuse Research: The Role of Social Media and Facebook Advertising

Background: The use of digital technology within health care service delivery, monitoring, and research is becoming progressively popular, particularly given the ongoing COVID-19 pandemic. Mobile health (m-health) apps, one form of digital technology, are increasingly being used to promote positive health related behavior change. Therefore, it is important to conduct research to understand the efficacy of m-health apps. The process of participant recruitment is an essential component in producing strong research evidence, along with ensuring an adequately powered sample to conduct meaningful analyses and draw robust conclusions. Methods: In this work we outline and reflect on the strategies used to recruit help-seeking military veterans into an intervention study, which aimed to evaluate the efficacy of an app (Drinks:Ration) to modify behavior in alcohol misusers. Recruitment strategies included through (1) partner organizations and (2) social media and Facebook advertising (ads). Results: Facebook ads were live for a period of 88 days and were viewed by a total audience of 29,416 people. In total 168 military veterans were recruited across all recruitment strategies, meaning that Drinks:Ration exceeded its recruitment targets. Half of the sample (n = 84) were recruited through social media, including Facebook ads. Conclusions: The current article highlighted that targeted Facebook ads were an efficient strategy to recruit military veterans into a digital intervention trial aiming to reduce alcohol consumption because they reduced the amount of time and resources required to contact a large number of potentially eligible individuals for our study. This article acts as a starting point for other researchers to evaluate their recruitment pathways for recruiting military veterans into alcohol misuse research.

Cost of post-deployment screening for mental illness in the UK military: findings from a cluster randomised controlled trial

BACKGROUND

Little is known about the economic impact of military mental health screening.

AIMS

To investigate (a) whether post-deployment screening of military personnel affects use and cost of services and (b) the impact of psychiatric morbidity on costs.

METHODS

Participants were recruited from UK Royal Marine and Army platoons and randomised to an intervention group (which received tailored advice predicated upon mental health status) or a control group (which received general advice following assessment of mental health status). The intervention costs were calculated while service use and associated costs were assessed at 12-month follow-up.

RESULTS

Data were available for 6323 participants. Mean screening cost was £34. Service costs were slightly higher in the control group compared to the intervention group (£1197 vs. £1147) which was not statistically significant (bootstrapped 95%CI, -£363 to £434. In both groups, screening and control, costs were significantly higher for those who screened positive for mental health problems.

CONCLUSIONS

Costs were not affected by screening. In countries that have already implemented post-deployment screening, the political cost of disinvestment needs careful consideration. Those who develop psychiatric morbidity have substantially higher care costs than those who do not.

'Treat everyone like they're a man': Stakeholder perspectives on the provision of health and social care support for female veterans in the UK

International research suggests that female veterans may experience gender-specific barriers to accessing veteran-specific care. This is the first UK study to report an exploratory qualitative investigation of the provision of health and social care support for female veterans and whether this support meets their needs. The research team carried out 13 virtual semi-structured interviews between October and November 2020, with representatives from statutory and third sector organisations that provide support to UK female veterans. Ethical approval was obtained from the Anglia Ruskin University School of Education and Social Care Research Ethics Committee. The authors identified four overarching themes and nine sub-themes in a thematic analysis following the framework outlined by Braun and Clarke (2006). The findings of this study suggest that practitioners from statutory and third sector organisations perceive the UK veteran support sector as male-dominated and male-targeted, with a lack of consideration for female veterans' needs. Participants reported a lack of engagement with veteran-specific services by female veterans and suggested that women either do not identify with the 'veteran' label or do not feel comfortable accessing male-dominated veteran-specific services. The need for specific services for female veterans split participant opinion, with most of those who were female veterans themselves highlighting the importance of 'safe spaces' for women, particularly those who had experienced gender-based violence during military service. Others felt that the veteran support sector currently lacked evidence of women's unique support needs, and an examination of current provision was required. The authors recommend a thorough assessment of UK female veterans' health and social care needs, alongside development of training and guidance for health and social care professionals, to ensure that veteran services are adequately developed, tailored and targeted with women's needs in mind.

A protocol for developing a complex needs indicator for veterans (CNIV) in the UK

Introduction

The veteran population in the UK has been decreasing, however, there remains a proportion of veterans and their families who continue to experience multiple and complex health, financial, and social needs. The complex problems tend to exacerbate each other and deepen over time if appropriate support is not provided. Identifying the veterans with complex needs is crucial for effective support by military charities and health and social care services. The present research aims to develop a complex needs indicator for the veteran population (CNIV) that will quantify complexity and help to identify the risk of having or developing complex needs.

Methods

The development of the CNIV will be informed by the guidance for constructing composite indicators. The data on grant support received by veterans' beneficiaries from the UK Royal Marine and SSFA charities will be used for designing the indicator and evaluating its robustness. The crucial step in constructing the indicator is assigning weights to different needs and risk factors associated with complex cases. Factor analysis (FA) and analytical network process (ANP) will be used as weighting methods for the analysed variables.

Conclusion

The development of CNIV has important implications for research and practice, such as the potential to be used as a screening tool for identifying complex cases, improved provision of the targeted support to veterans, assessing the scope of complex problems among veterans within the country and informing policy makers and a more general audience of the complexity of need within the sector.

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.

A Qualitative Exploration of the Experiences of Veterans Who Are Serving Sentences in Custody

The focus on veterans in research is not a novel topic; however, the majority of studies are related to trauma, employment, mental health, suicide, and substance misuse. The criminal justice system involvement with veterans is a topic that has yet to be examined to a great extent. This study, conducted with adult male prisoners, elicited information from six veterans regarding their experiences of being in the armed forces, leaving the armed forces, and becoming involved in the criminal justice system. Responses were evaluated using interpretative phenomenological analysis (IPA) and three main themes were identified: "you're baptized into the army," "them and us," and "operational mind-set"; each of which comprised a number of superordinate themes. The research highlights that although it is important to acknowledge the heterogenic nature of this group, it is equally important to note that much of their thinking and behavior may be similar to those that have not had these experiences. As such, there is a need to reduce the notion that they are separate and different to other prisoners, requiring different treatment. The study highlights that many of the offending behavior programs and interventions already available to prisoners would be appropriate for this group. The current research supports the merit in creating a service in prisons that will allow ex-servicemen to meet together and access the support that is available to them. The implications of the research are discussed further.

Combat exposure and co-occurring mental health problems in UK Armed Forces personnel

ABSTARCTBackground: Mental disorders and alcohol misuse are often comorbid, and this comorbidity is more common in those who develop mental disorders following exposure to traumatic events.Aims: To investigate the relationship between combat exposure and operational role (support versus combat) with mental disorders and associated comorbidity in a UK military cohort.Methods: 4896 participants from a UK military cohort reported their operational role and frequency of exposure to combat events during deployment. Outcome measures included self-reported post-traumatic stress disorder, common mental disorder and alcohol misuse.Results: Personnel reporting higher levels of combat exposure were more likely to meet criteria for two or more co-occurring mental disorders (odds ratio [OR] 3.90, 95% confidence interval [CI] 2.73-5.58). While having a combat role increased the risk of developing co-occurring disorders compared to having a support role (OR 1.67, 95% CI 1.26-2.23), this effect diminished following adjustment for variables including combat exposure (OR 0.89, 95% CI 0.62-1.27).Conclusions: Combat exposure may play a greater role in the development of comorbid mental disorders than operational role, i.e. job title. Clinicians treating military personnel should be alert to the increased risk of comorbid mental disorders and alcohol misuse among those with a history of combat exposure.

Influence of hardiness, avoidance coping, and combat exposure on depression in returning war veterans: A moderated-mediation study

BACKGROUND

Depression is a serious problem among military personnel returning from combat deployments, and is related to a range of adverse outcomes including alcohol and drug abuse, family violence and suicide. The present study explores how psychological hardiness, avoidance coping, and combat stress exposure may influence depression in U.S. Army soldiers returning from a one-year deployment to Afghanistan.

METHODS

National Guard soldiers (N = 357) completed surveys upon their return to home station, including measures of hardiness, avoidance coping, combat exposure, and depression. Path analysis with ordinary least squares regression procedures (PROCESS program; Hayes, 2013) were applied to test for mediation and moderation effects among the study variables.

RESULTS

Results showed a pattern of moderated-mediation. In the mediation model, hardiness had a significant effect on depression, which was mediated by avoidance coping. Soldiers low in hardiness reported using more avoidance coping strategies, which was related to increased depression. This effect in turn was seen to be conditional, moderated by level of combat exposure such that the effect was stronger at high levels of exposure.

LIMITATIONS

Data are cross-sectional, and the sample consisted of male soldiers only, which may limit generalizability.

CONCLUSIONS

Depression and related problems among combat veterans may be diminished by applying training programs and policies aimed at increasing hardiness attitudes and active coping skills.

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Comparison of past-year mental health services use in Canadian Army, Navy, and Air Force personnel

Introduction: What causes the excess burden of mental disorders and related outcomes in the Army remains unclear. Deployment-related trauma has been one intuitive explanation. However, there may be other factors at play – for example, lower mental health services use (MHSU) in Army personnel. This study compares MHSU across the Canadian Army, Navy, and Air Force. Methods: Data were drawn from the 2013 Canadian Forces Mental Health Survey. The sample consisted of Regular Force members ( N = 6,696). The primary outcomes for past-year MHSU were: (1) any past-year MHSU; (2) intensity of care (total clinical contact hours), and (3) perceived helpfulness of care (PHC). ­Modified Poisson regression and analysis of covariance (ANCOVA) were used to assess the relationship between the elements (Army, Navy, Air Force) and each outcome, adjusting for sociodemographic and military characteristics, as well as clinical variables such as the presence of five past-year mental disorders. Results: In unadjusted analyses, Army personnel had significantly greater past-year MHSU and intensity of care relative to Air Force personnel. No significant relationship was found between the element and any of the MHSU parameters after adjustment. Discussion: Differences in past-year MHSU are an unlikely contributing factor to the higher risk of mental disorders and related outcomes among Army personnel; the true explanation must lie elsewhere. Findings argue for a system-wide, and not element-specific, approach to improving Canadian Armed Forces (CAF) programs and services.

Adapting CBT to treat depression in Armed Forces Veterans: qualitative study

BACKGROUND

The principles of the Armed Forces Covenant state that Armed Forces Veterans should be at no disadvantage resulting from their service compared with a general adult population. However, despite being at increased risk of experiencing common mental health difficulties, evidence indicates that 82% of Armed Forces Veterans receive no treatment, compared with 63% of the general adult population.

AIM

To gain a better appreciation of factors that inform the type of adaptations to cognitive behavioural therapy (CBT) interventions for depression and mainstream service promotion materials to enhance acceptability for Armed Forces Veterans.

METHOD

This is a qualitative study employing a focus group of 12 participants to examine the main impacts of depression on Armed Forces Veterans alongside attitudes towards terminology and visual imagery. Thematic analysis was used to identify themes and sub-themes with rigour established through two researchers independently developing thematic maps to inform a final agreed thematic map.

RESULTS

A behavioural activation intervention supporting re-engagement with activities to overcome depression had good levels of acceptability when adapted to reflect an Armed Forces culture. Preferences regarding terminology commonly used within CBT adapted for Armed Forces Veterans were identified. Concerns were expressed with respect to using imagery that emphasized physical rather than mental health difficulties.

CONCLUSIONS

There is the need to consider the Armed Forces community as a specific institutional culture when developing CBT approaches with potential to enhance engagement, completion and recovery rates. Results have potential to inform the practice of CBT with Armed Forces Veterans and future research.

The return of the traumatized army veteran: a qualitative study of UK ex-servicemen in the aftermath of war, 1945 to 2000

The challenge of transition from service to civilian life is explored through the experiences of a sample of 225 UK army veterans between 1945 and 2000. All subjects had a war pension for a psychological disorder, and most had served overseas in combat roles. Statements about issues of adjustment and health were analyzed by the constant comparison method. Although 20 themes were identified, three ('anxiety, nerves and depression', 'enduring illness attributed to combat exposure', and 'illness interferes with the ability to find or keep employment') accounted for 46% of the total and were reported by between 53% and 86% of subjects. Consistency was observed in the ranking of themes over time. In content, they replicate those reported by veterans of recent conflicts, suggesting that the core issues of transition have an enduring quality. Most statements (66%) date from the 1940s, a time when the application process for a pension required the veteran to provide an explanation for his illness. A rise in the number of statements during the 1980s and 1990s reflected wider cultural acceptance of post-traumatic illness and veteran population entering retirement with time to reflect on defining experiences.

Relationship between obesity and health problems in help-seeking military veterans

Background

UK Armed Forces (UK AF) veterans may be particularly vulnerable to obesity and its comorbid physical and mental health problems.

Aim

To examine the relationship between body mass index (BMI), physical health problems, mental health disorders and sociodemographic characteristics in UK AF veterans engaged in psychological treatment.

Methods

Information regarding veteran BMI, demographic characteristics, physical health conditions and mental health problems was collected and analysed using univariate and multivariate regression analyses. Rates of veteran obesity were also compared with the UK general population.

Results

Of the 384 help-seeking veterans, 37.5% (n=151) were overweight (BMI 26–30) and 35.5% (n=143) were obese. Obesity in help-seeking male veterans was two to four times higher than that of the general population of UK. Higher scores on measures of anger and common mental health problems were significantly associated with greater BMI. Problems with physical systemic functioning and mobility were also significantly associated with greater BMI.

Conclusions

The results indicate that treatment-seeking UK AF veterans exhibit higher levels of obesity compared with the general population, and clinically significant physical and mental comorbidities. The findings highlight a need for mental health services to offer treatments that effectively integrate physical and mental healthcare in the treatment of people with mental health problems.

A latent profile analysis of PTSD symptoms among UK treatment seeking veterans

Background: Significant numbers of individuals leave the military and experience symptoms of posttraumatic stress disorder (PTSD). Veterans with PTSD symptoms rarely experience them in isolation, more commonly they are co-morbid with a range of other difficulties. Objective: Latent profile analysis (LPA) was used to explore the heterogeneity of PTSD symptom presentation. Following this, regression analysis was used to examine variables that predicted membership to the identified PTSD profiles. Methods: Data on childhood adversity, socio-demographic characteristics and mental health outcomes was collected from 386 male veterans who had engaged with mental health services in the UK. Results: LPA identified a six-profile model to best describe the sample. There was a Low symptom profile, a Severe symptom profile and four Moderate symptom profiles. The Severe symptom profile was the largest one, accounting for 37.57% of the sample. Five out of the six profiles had mean PTSD scores above the cut-off for probable PTSD. Higher rates of common mental health difficulties were associated with more symptomatic profiles. Discussion: As the vast majority of veterans met criteria for probable PTSD, the finding of six different profiles differing primarily quantitatively, but to some extent also qualitatively, suggests the importance of moving away from a 'one-size fits all' approach when it comes to treatments, towards developing interventions that are tailored to meet the specific PTSD and co-morbid symptoms profiles.

Mental health outcomes at the end of the British involvement in the Iraq and Afghanistan conflicts: a cohort study

BACKGROUND

Little is known about the prevalence of mental health outcomes in UK personnel at the end of the British involvement in the Iraq and Afghanistan conflicts.AimsWe examined the prevalence of mental disorders and alcohol misuse, whether this differed between serving and ex-serving regular personnel and by deployment status.

METHOD

This is the third phase of a military cohort study (2014-2016; n = 8093). The sample was based on participants from previous phases (2004-2006 and 2007-2009) and a new randomly selected sample of those who had joined the UK armed forces since 2009.

RESULTS

The prevalence was 6.2% for probable post-traumatic stress disorder, 21.9% for common mental disorders and 10.0% for alcohol misuse. Deployment to Iraq or Afghanistan and a combat role during deployment were associated with significantly worse mental health outcomes and alcohol misuse in ex-serving regular personnel but not in currently serving regular personnel.

CONCLUSIONS

The findings highlight an increasing prevalence of post-traumatic stress disorder and a lowering prevalence of alcohol misuse compared with our previous findings and stresses the importance of continued surveillance during service and beyond.

DECLARATION OF INTEREST

All authors are based at King's College London which, for the purpose of this study and other military-related studies, receives funding from the UK Ministry of Defence (MoD). S.A.M.S., M.J., L.H., D.P., S.M. and R.J.R. salaries were totally or partially paid by the UK MoD. The UK MoD provides support to the Academic Department of Military Mental Health, and the salaries of N.J., N.G. and N.T.F. are covered totally or partly by this contribution. D.Mu. is employed by Combat Stress, a national UK charity that provides clinical mental health services to veterans. D.MacM. is the lead consultant for an NHS Veteran Mental Health Service. N.G. is the Royal College of Psychiatrists' Lead for Military and Veterans' Health, a trustee of Walking with the Wounded, and an independent director at the Forces in Mind Trust; however, he was not directed by these organisations in any way in relation to his contribution to this paper. N.J. is a full-time member of the armed forces seconded to King's College London. N.T.F. reports grants from the US Department of Defense and the UK MoD, is a trustee (unpaid) of The Warrior Programme and an independent advisor to the Independent Group Advising on the Release of Data (IGARD). S.W. is a trustee (unpaid) of Combat Stress and Honorary Civilian Consultant Advisor in Psychiatry for the British Army (unpaid). S.W. is affiliated to the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emergency Preparedness and Response at King's College London in partnership with Public Health England, in collaboration with the University of East Anglia and Newcastle University. The views expressed are those of the author(s) and not necessarily those of the National Health Service, the NIHR, the Department of Health, Public Health England or the UK MoD.

Systematic review of lessons learned from delivering tele-therapy to veterans with post-traumatic stress disorder

Introduction Despite increases in the number of ex-service personnel seeking treatment for post-traumatic stress disorder (PTSD), there remain a number of barriers to help-seeking which prevents many veterans from accessing psychological therapies. Tele-therapy provides one potential method of increasing the number of veterans accessing support. This review aimed to systematically review the literature in order to summarise what lessons have been learned so far from providing trauma-focused tele-therapies to veterans with PTSD. Methods A systematic literature review was conducted from which 41 papers were reviewed. Studies were included if they involved the use of trauma-focused therapies carried out using tele-therapy technologies. Only studies using tele-therapy interventions via video or telephone with populations of ex-military personnel with PTSD were included. Results In the majority of cases tele-therapy was found to be as effective in reducing PTSD symptoms as in-person interventions. Similarly, there were few differences in most process outcomes such as dropout rates, with tele-therapy helping to increase uptake in some cases. Veterans using tele-therapy reported high levels of acceptability and satisfaction. Some challenges were reported in terms of therapeutic alliance, with some studies suggesting that veterans felt less comfortable in using tele-therapy. Several studies suggested it was harder for clinicians to read non-verbal communication in tele-therapy, but this did not affect their ability to build rapport. Technological issues were encountered, but these were not found to impede therapy processes or outcomes. Discussion Tele-therapy provides a viable alternative to in-person therapies and has the potential to increase access to therapy for veterans. Tele-therapy should continue to be evaluated and scrutinised in order to establish the most effective methods of delivery.

UK extended Medical Assessment Programme for ex-service personnel: the first 150 individuals seen

Aims and method

To describe an interim service set up to examine the breadth of UK ex-service personnel's concerns in relation to their mental health and military service and provide a record of the first 150 individuals assessed following conformation of military service and examination of all available military and civilian medical records.

Results

The majority of attendees were White male ex-soldiers. Average age, service and time to assessment were 44.5, 15.8 and 11.7 years respectively. Two-thirds were receiving help from the National Health Service and ex-service nongovernmental organisations. Rates of post-traumatic stress disorder were similar to previous UK studies. Obsessional symptoms were of relevance to the clinical presentation in a third. Fabrication and/or exaggeration occurred in about 10%.

Clinical implications

The spread of diagnoses and delay in help-seeking are similar to civilians. The link between mental disorders and military service is seldom straightforward and fabrication or exaggeration is difficult for civilians to recognise. Verification and contextualisation of service using contemporaneous service medical records is important given the possible occupational origin of mental health conditions.

Patient characteristics and clinical activities at a British military department of community mental health

Aims and Method

To describe patient characteristics and clinical activities at a British military department of community mental health (DCMH). Data were drawn from a clinical database over a 1-year period (n=409).

Results

Mean age was 29 years, 50% were single and 76% were from the junior ranks. Women were over-represented compared with the wider military population. Mean length of service prior to presentation was 5 years. The main presenting problem was alcohol misuse (33%) followed by depression (19%). Twenty-five per cent were referred for psychotherapy and 68% returned to full employment after treatment.

Clinical Implications

Patient characteristics of those treated at a DCMH differ from those in the wider military. An out-patient occupational mental health service returns a substantial number of patients to occupational fitness within the Armed Forces.

Mental health of regular and reserve military veterans

The psychiatric problems of combat returnees are a topical and important issue given the ongoing conflicts in Iraq and Afghanistan. Despite the media prominence afforded to post-traumatic stress disorder, the most common disorders in the UK armed forces post-deployment are depression, alcohol misuse and anxiety disorders. Although the majority of service personnel do well after leaving military life, a minority who leave with psychiatric problems appear to be at risk of social exclusion and ongoing ill health. Reserve veterans are at greater risk as they do not have access to the usual support networks of the regular military. Steps to improve the knowledge and expertise of primary care services about veterans' mental health issues and increasing the availability of treatment options are important and are underway.

The mental health of military veterans in the UK

Risk factors for poor mental health among UK veterans include demonstrating symptoms while in service, being unmarried, holding lower rank, experiencing childhood adversity and having a combat role; however, deploy ment to a combat zone does not appear to be associated with mental health outcomes. While presentation of late-onset, post-service difficulties may explain some of the difference between veterans and those in service, delayed-onset post-traumatic stress disorder (PTSD) appears to be partly explained by prior subthreshold PTSD, as well as other mental health difficulties. In the longer term, veterans do not appear to suffer worse mental health than equivalent civilians. This overall lack of difference, despite increased mental health difficulties in those who have recently left, suggests that veterans are not at risk of worse mental health and/or that poor mental health is a cause, rather than a consequence, of leaving service.

Posttraumatic Stress Disorder and Somatic Complaints in a Deployed Cohort of Georgian Military Personnel: Mediating Effect of Depression and Anxiety

Several studies have shown the relationship between symptoms of posttraumatic stress disorder (PTSD), somatic symptoms, and the mediating effect of depression and anxiety. The following study was conducted to investigate the relationship between PTSD symptoms and somatic complaints through underlying symptoms of depression and anxiety. The participants of the study were 2,799 veterans who were examined after a 6-month deployment. They were assessed using the PTSD Checklist (PCL-5) and Patient Health Questionnaire (PHQ) for depression, anxiety, and somatic complaints. To check the indirect effect of PTSD on somatic complaints through depression and anxiety, mediation model 4 (parallel mediation) of the SPSS PROCESS macro was used. There was a significant total indirect effect of PTSD through depression and anxiety on somatic complaints, b = 0.14, 95% confidence interval (CI) [0.12, 0.16], from which an indirect effect of PTSD on somatic complaints through depression was b = 0.08, 95% CI [0.06, 0.10], and through anxiety it equaled b = 0.06, 95% CI [0.04, 0.07]. The ratio of indirect to total effect was 0.66, 95% CI [0.59, 0.75]. The present study helps us to understand the role of depression and anxiety symptoms when the symptoms of PTSD and somatic complaints are present. These new findings may have implications for the management as well as treatment of PTSD because they recognize the importance of symptoms of anxiety and depression when somatic complaints are present.

Pathways into mental health care for UK veterans: a qualitative study

Background: It is well established that veterans suffering from mental health difficulties under use mental health services. Objective: This study aimed to understand more about the barriers that prevent veterans from seeking professional help and the enablers that assist veterans in seeking professional help. It also aimed to explore potential mechanisms to improve veterans' help-seeking and pathways to care. Method: The study employed a qualitative design whereby 17 veterans who had recently attended specialist veteran mental health services took part in semi-structured interviews. The resultant data were analysed using grounded theory. Results: Participants described two distinct stages to their help-seeking: initial help-seeking and pathways through treatment. Specific barriers and enablers to help-seeking were identified at each stage. Initial barriers included recognizing that there is a problem, self-stigma and anticipated public stigma. Initial enablers included being in crisis, social support, motivation and the media. Treatment pathway barriers included practical factors and negative beliefs about health services and professionals. Treatment pathway enablers included having a diagnosis, being seen in a veteran-specific service and establishing a good therapeutic relationship. Participants provided some suggestions for interventions to improve veterans' help-seeking in future; these focussed on enhancing both veterans and health professionals' knowledge regarding mental health difficulties. Conclusions: This study identified a number of barriers and enablers that may impact a veteran's journey in seeking help from professional services for mental health difficulties. Enablers such as reaching a crisis point, social support, the media, having a diagnosis of PTSD and veteran-specific mental health services appeared to be important in opposing stigma-related beliefs and in supporting veterans to engage in help-seeking behaviours.

Military veteran engagement with mental health and well-being services: a qualitative study of the role of the peer support worker

Background: Many UK military veterans experiencing mental health and well-being difficulties do not engage with support services to get the help they need. Some mental health clinics employ Peer Support Workers (PSWs) to help veteran patients engage, however it is not known how the role influences UK veteran engagement.Aims: To gain insight into the role of peer support in UK veteran engagement with mental health and well-being services.Method: A qualitative study based on 18 semi-structured interviews with veterans, PSWs and mental health clinicians at a specialist veteran mental health and well-being clinic in Scotland.Results: Four themes of the PSW role as positive first impression, understanding professional friend, helpful and supportive connector, and an open door were identified across all participants. The PSWs' military connection, social and well-being support and role in providing veterans with an easily accessible route to dis-engage and re-engage with the service over multiple engagement attempts were particularly crucial.Conclusions: The Peer Support role enhanced veteran engagement in the majority of instances. Study findings mirrored existing peer support literature, provided new evidence in relation to engaging UK veterans, and made recommendations for future veteran research and service provision.

The mental health and substance misuse needs of male ex-armed forces personnel in prison

Ex-armed forces personnel constitute the largest known occupational group in prison but there is little evidence regarding their mental health, or substance misuse, needs. A total of 105 participants were interviewed and measures assessing symptoms of common mental health (CMH) problems and substance misuse were completed along with a review of their health care records. Forty (38%) participants screened for current CMH problems (CCMH) and high levels of dual symptomology and alcohol misuse were assessed. Thirty-nine (37%) had a mental health diagnosis recorded, most commonly for post-traumatic stress disorder (PTSD), depression and personality disorder. Those who screened for a CCMH problem were more likely to have pre-service vulnerability to negative health outcomes and those with dual symptomology were more likely to have experienced deployment during their service. Findings suggest the mental health needs of this group are similar to the general prison population. Potentially higher prevalences of PTSD and alcohol misuse may direct service provision.

Treatment Barriers and Support for Male Ex-Armed Forces Personnel in Prison: Professional and Service User Perspectives

Ex-armed forces personnel represent a potentially vulnerable group within the prison population. To provide support to this group, we need to understand their needs and help-seeking behavior. A focus group with professionals and semi-structured interviews with service users explored perspectives of the treatment barriers faced by this group and their support needs. Data were analyzed using constant comparison methods, and four primary themes were identified. The findings suggest ex-armed forces personnel consider prison an opportunity to access support but find it difficult to ask for help. Staff having an awareness of military issues was thought to encourage help-seeking, but the variability of provision across prison establishments was considered a barrier. Resettlement was a prominent concern, and access to support when preparing for, and after, release was felt by all participants to be important. Implications for the provision of support in prison are discussed along with recommendations for practice.

Protocol for the evaluation of a digital storytelling approach to address stigma and improve readiness to seek services among veterans

BACKGROUND

Research suggests that at least 10% of veterans returning from Iraq and Afghanistan meet criteria for posttraumatic stress disorder (PTSD) related to their military experiences. National dissemination initiatives have increased veterans' access to best-practice interventions. However, treatment-seeking remains low among veterans with PTSD, often due to perceived stigma and other associated barriers. The National Center for PTSD recently developed and launched AboutFace, a digital storytelling (DST) resource designed to help veterans recognize PTSD and motivate them to seek evidence-based treatment. The Ralph H. Johnson Veterans Affairs Medical Center (VAMC) and the National Center for PTSD have partnered to conduct pilot work to evaluate veterans' reactions to AboutFace to set the stage for a large-scale study to examine whether AboutFace effectively reduces stigma and improves attitudes toward treatment-seeking among veterans. If effective, this DST approach may serve as a valuable national model for a variety of treatment-seeking populations.

METHODS

During the first phase of the pilot, in-person usability assessments of AboutFace will be conducted via semi-structured interviews with 20 veterans. Audio recordings of interviews will undergo transcription and coding. A report of the results of qualitative analyses of these interviews will be provided to the National Center for PTSD and will inform revisions to the site. In the second phase of the pilot, 60 veterans referred to a specialized PTSD clinic will be recruited to demonstrate and refine the methodology that we propose to use in a larger randomized controlled trial evaluation of AboutFace. Veterans will be randomly assigned to receive AboutFace plus standard education vs. standard education alone. Baseline and 2-week telephone assessments will be conducted with participating veterans to measure stigma, attitudes toward seeking mental health services, and treatment access/engagement.

DISCUSSION

The feedback we receive in this pilot will be used to strengthen the quality of the DST website in preparation for a large-scale evaluation. Future work will involve evaluation of reach and impact of the site relative to stigma, attitudes toward seeking mental health service, and utilization of care. If AboutFace is found to increase access to care, this finding would have broad and significant implications for overcoming barriers to care for veterans and other populations with stigmatized conditions.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02486692.

A review of the physiological and psychological health and wellbeing of naval service personnel and the modalities used for monitoring

Naval cohorts rely heavily on personnel to ensure the efficient running of naval organisations. As such, the wellbeing of personnel is essential. In an occupational setting, naval service personnel experience a variety of physiological and psychological stressors. Most naval services arrange annual physical fitness and body composition tests to ensure the physical readiness of personnel. However, these tests only evaluate a small amount of physiological capabilities. Components such as aerobic and strength capabilities are assessed, however, other components of physical fitness such as speed, agility, anaerobic capacity and flexibility are not. In addition to the physical capabilities, personnel are impacted by fatigue, nutrition and psychological stressors such as copping in stressful situations or dealing with time away from family and friends. This review will discuss the physiological and psychological factors that affect personnel's wellbeing. In addition to this, it will also evaluate the methods that are used to assess both physiological and psychological wellbeing.

Systematic review of mental health disorders and intimate partner violence victimisation among military populations

PURPOSE

There is growing awareness of the problem of intimate partner violence (IPV) among military populations. IPV victimisation has been shown to be associated with mental disorder. A better understanding of the link between IPV and mental disorder is needed to inform service development to meet the needs of military families. We aimed to systematically review the literature on the association between IPV victimisation and mental health disorders among military personnel.

METHODS

Searches of four electronic databases (Embase, Medline, PsycINFO, and Web of Science) were supplemented by reference list screening. Heterogeneity among studies precluded a meta-analysis.

RESULTS

Thirteen studies were included. There was stronger evidence for an association between IPV and depression/alcohol problems than between IPV and PTSD. An association between IPV and mental health problems was more frequently found among veterans compared to active duty personnel. However, the link between IPV and alcohol misuse was more consistently found among active duty samples. Finally, among active duty personnel psychological IPV was more consistently associated with depression/alcohol problems than physical/sexual IPV. The review highlighted the lack of research on male IPV victimisation in the military.

CONCLUSIONS

There is evidence that the burden of mental health need may be significant among military personnel who are victims of IPV. The influence of attitudes towards gender in the military on research in this area is discussed. Further research is needed to inform development of services and policy to reduce IPV victimisation and the mental health consequences among military personnel.

A non-inferiority trial of Prolonged Exposure for posttraumatic stress disorder: In person versus home-based telehealth

This is the first randomized controlled trial to evaluate non-inferiority of Prolonged Exposure (PE) delivered via home-based telehealth (HBT) compared to standard in-person (IP) PE. One-hundred thirty two Veterans recruited from a Southeastern Veterans Affairs Medical Center and affiliated University who met criteria for posttraumatic stress disorder (PTSD) were randomized to receive PE via HBT or PE via IP. Results indicated that PE-HBT was non-inferior to PE-IP in terms of reducing PTSD scores at post-treatment, 3 and 6 month follow-up. However, non-inferiority hypotheses for depression were only supported at 6 month follow-up. HBT has great potential to reduce patient burden associated with receiving treatment in terms of travel time, travel cost, lost work, and stigma without sacrificing efficacy. These findings indicate that telehealth treatment delivered directly into patients' homes may dramatically increase the reach of this evidence-based therapy for PTSD without diminishing effectiveness.

Long-term responses to treatment in UK veterans with military-related PTSD: an observational study

OBJECTIVES

Military-related trauma can be difficult to treat. Evaluating longer term responses to treatment and identifying which individuals may need additional support could inform clinical practice. We assessed 1-year outcomes in UK veterans treated for post-traumatic stress disorder (PTSD).

DESIGN

Within-participant design.

SETTING

The intervention was offered by Combat Stress, a mental health charity for veterans in the UK.

PARTICIPANTS

The sample included 401 veterans who completed a standardised 6-week residential treatment. Of these, 268 (67%) were successfully followed up a year after the end of treatment.

METHODS

A range of health outcomes were collected pretreatment and repeated at standard intervals post-treatment. The primary outcome was severity of PTSD symptoms, and secondary outcomes included measures of other mental health difficulties (depression, anxiety and anger), problems with alcohol, and social and occupational functioning.

RESULTS

Significant reductions in PTSD severity were observed a year after treatment (PSS-I: -11.9, 95% CI -13.1 to -10.7). Reductions in the secondary outcomes were also reported. Higher levels of post-treatment functional impairment (0.24, 95% CI 0.08 to 0.41) and alcohol problems (0.18, 95% CI 0.03 to 0.32) were associated with poorer PTSD treatment response at 12 months.

CONCLUSIONS

This uncontrolled study suggests the longer term benefits of a structured programme to treat UK veterans with PTSD. Our findings point to the importance of continued support targeted for particular individuals post-treatment to improve longer term outcomes.

Psychometric validation of the 16 Item Quick Inventory of Depressive Symptomatology Self-Report Version (QIDS-SR16) in military veterans with PTSD

BACKGROUND

The Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR16) is one example of a screening tool for depression, which has been utilized extensively following validation in a number of clinical populations. Despite the strengths of the QIDS-SR16, it has not been validated in military veterans, a particularly unique population considering their exposure to trauma and high rate of psychiatric comorbidities. The current report describes a psychometric validation of the QIDS-SR16 in a sample of United States military veterans diagnosed with military-related PTSD.

METHODS

Participants (n=240) were administered the QIDS-SR16 and one of two gold-standard semi-structured interviews to establish diagnosis of a current Major Depressive Episode (MDE). The ability to discriminate between individuals with and without a current MDE using the QIDS-SR16 was tested with a stepwise logistic regression. Additionally, an optimal cutoff score for the QIDS-SR16 was established.

RESULTS

The QIDS-SR16 was able to reliabily discriminate between individuals with and without a current MDE. The optimal cutoff score of the QIDS-SR16 for a current MDE was 13, with a sensitivity of 77.55% and specificity of 56.25%.

LIMITATIONS

Limitations of this study included underrepresentation of some racial/ethnic groups, the inability to disentangle the potential influence of trauma type and gender on results, and the use of two diagnostic interviews to diagnose current MDE.

DISCUSSION

The QIDS-SR16 can be effectively utilized in military veterans with comorbid PTSD. However, the calculated cutoff score for this population was higher than the cutoff score for the general population. This could result from the overlap between PTSD and MDE symptoms.

Soldier, civilian, criminal: identifying pathways to offending of ex-armed forces personnel in prison

Little is known about why some ex-armed forces personnel become involved in the criminal justice system, however, they represent the largest known occupational group in prison. In-depth interviews were employed to explore possible pathways to offending. Twenty ex-armed forces personnel in prison were recruited from five prisons in England. Data were analysed using a combination of thematic analysis and constant comparison methods rooted in grounded theory. Four predominant themes were identified: experiences of trauma and adversity; belonging; impulsivity and creating a soldier. Participants had experienced a number of traumatic incidents and adversity in their lives, encompassing pre, during and post-service but felt a sense of belonging in the armed forces. Participants demonstrated impulsivity in a number of areas with links to both their service in the armed forces and offending behaviour. The creation of the identity of 'soldier' was perceived to impact participants' lives in a number of ways, including their offending, alcohol use and coping with trauma. The interplay of these themes and their potential impact on participants' pathways to offending are discussed.

The mental health of fire-fighters: An examination of the impact of repeated trauma exposure

OBJECTIVE

Emergency workers, such as fire-fighters, are routinely exposed to potentially traumatic events. While a number of studies have examined the occurrence of post-traumatic stress disorder, the role of multiple traumas on other mental health sequelae, such as depression and alcohol misuse, among emergency workers remains unclear. This study aimed to assess the prevalence of post-traumatic stress disorder, depression and alcohol misuse in a sample of current and retired fire-fighters and examine their relationship with cumulative trauma exposure.

METHOD

A cross-sectional survey was completed by current (n = 488) and retired (n = 265) fire-fighters from Fire and Rescue New South Wales, Australia. Demographic and occupational information was collected, including the number of fatal incidents fire-fighters reported attending across years of service. Validated, self-report measures were used to determine probable caseness for post-traumatic stress disorder, depression and heavy drinking.

RESULTS

Among current fire-fighters, rates of post-traumatic stress disorder and depression were 8% and 5%, respectively, while 4% reported consumption of more than 42 alcoholic drinks per week. Retired fire-fighters reported significantly greater levels of symptomatology, with the prevalence estimates of post-traumatic stress disorder at 18% (p = 0.001), depression at 18% (p < 0.001) and heavy drinking at 7%. There was a significant positive linear relationship between the number of fatal incidents attended and rates of post-traumatic stress disorder, depression and heavy drinking.

CONCLUSION

Fire-fighters suffer from high rates of mental disorders, with rates of post-traumatic stress disorder, depression and heavy drinking continuing to rise in a linear manner with each additional trauma exposure. The level of psychiatric morbidity among retired fire-fighters appears to be particularly high. Our findings have important implications for the ongoing debates surrounding the detection of mental disorders in high-risk occupations and for policy considerations around the welfare of current and retired emergency workers.

Outcomes from a pilot psychological therapies service for UK military veterans

Aim

To evaluate the outcomes of participants attending a psychological therapies service for military veterans.

Background

The UK Military Veterans’ Improving Access to Psychological Therapies Service (North West) (MV IAPT) provided a clinical psychological therapies service for military veterans. Outcomes of depression, anxiety and social adjustment were assessed after treatment in the service's pilot phase.

Design

An observational, prospective cohort study examined changes in depression, anxiety and social adjustment during receipt of the service.

Methods

Changes in depression (PHQ‐9), anxiety (GAD‐7) and social adjustment (WSAS) were examined in 952 veterans referred over 20 months from September 2011. Data were collected using the IAPT clinical information system plus additional fields. Changes for patients who completed treatment, remained in treatment and dropped out were compared.

Results

Seven hundred and seven veterans received an initial assessment, from which 505 received two or more appointments. Of these, 156 completed treatments, 179 remained in treatment and 170 dropped out. The majority of veterans had been operationally deployed and were similar in risk characteristics to those in other military cohort studies. There were highly significant improvements on all measures (p<.01), with completers improving more and having higher rates of recovery from depression and anxiety than those remaining and drop outs. Recovery rates compared favourably with evaluations of general IAPT services and also exceeded reported natural recovery rates.

Major depression and depressive symptoms in Australian Gulf War veterans 20 years after the Gulf War

BACKGROUND

Risk of major depression (depression) was elevated in Australia's Gulf War veterans in a 2000-2002 (baseline) study. A follow up study has measured the Gulf War-related risk factors for depression, also the current prevalence and severity of depression, use of anti-depressant medication, and persistence, remittance or incidence of depression since baseline in Gulf War veterans and a military comparison group.

METHODS

Participants completed the Composite International Diagnostic Interview v.2.1, the 9-item Patient Health Questionnaire and the Military Service Experience Questionnaire, and consented to Repatriation Pharmaceutical Benefits Scheme (RPBS) and PBS linkage.

RESULTS

Prevalence of depression (9.7% Gulf War veterans and 7.7% comparison group; adj RR=1.2, 95% CI 0.8-1.7), and pattern of persistence, remittance and incidence of depression since baseline, were similar in the two groups, however veterans reported slightly more severe symptoms (adj median difference 1, 95% CI 0.26-1.74) and were more likely to have been dispensed anti-depressant medication (adj RR=1.56, 95% CI 1.05-2.32). Depression amongst veterans was associated with self-reported Gulf War-related stressors in a dose-response relationship (adj RR 1.06, 95% CI 1.02-1.09).

LIMITATIONS

Lower participation rates at follow up resulted in reduced statistical power compared with baseline, Gulf War related stressor data collected at baseline was at risk of recall bias, and RPBS and PBS databases do not capture all dispensed Nervous System medications.

CONCLUSIONS

More than 20 years after the Gulf War, veterans are experiencing slightly more severe depressive symptoms than a military comparison group, and depression continues to be associated with Gulf War-related stressors.

Help for heroes? Evaluating a case management programme for ex-service personnel in the United Kingdom

AIMS

There is increasing recognition of the health and social needs of ex-service personnel, but the UK evidence base on interventions is small. This article presents the findings from an evaluation of a vocational case management programme co-funded by the National Health Service (NHS) to prevent ill health among ex-service personnel.

METHODS

Qualitative, semi-structured interviews with 15 ex-service personnel were conducted. Five interviews with case management staff were also undertaken. Data were transcribed, thematically coded and analysed using NVivo.

RESULTS

Ex-service personnel valued the service and consistently highlighted 'being listened to', 'being made to feel valued by programme staff', 'having their problems taken seriously' and 'being treated as an individual' as the most valuable aspects of the programme. Respondents particularly valued the personal support that case managers provided and the environment in which the service was delivered.

CONCLUSION

Case management is a viable way in which the military, health professionals and support services can provide ongoing support for ex-service personnel in transitioning successfully to civilian life.

Stigma as a barrier to seeking health care among military personnel with mental health problems

Approximately 60% of military personnel who experience mental health problems do not seek help, yet many of them could benefit from professional treatment. Across military studies, one of the most frequently reported barriers to help-seeking for mental health problems is concerns about stigma. It is, however, less clear how stigma influences mental health service utilization. This review will synthesize existing research on stigma, focusing on those in the military with mental health problems. We conducted a systematic review and meta-analysis of studies between 2001 and 2014 to examine the prevalence of stigma for seeking help for a mental health problem and its association with help-seeking intentions/mental health service utilization. Twenty papers met the search criteria. Weighted prevalence estimates for the 2 most endorsed stigma concerns were 44.2% (95% confidence interval: 37.1, 51.4) for "My unit leadership might treat me differently" and 42.9% (95% confidence interval: 36.8, 49.0) for "I would be seen as weak." Nine studies found no association between anticipated stigma and help-seeking intentions/mental health service use and 4 studies found a positive association. One study found a negative association between self-stigma and intentions to seek help. Counterintuitively, those that endorsed high anticipated stigma still utilized mental health services or were interested in seeking help. We propose that these findings may be related to intention-behavior gaps or methodological issues in the measurement of stigma. Positive associations may be influenced by modified labeling theory. Additionally, other factors such as self-stigma and negative attitudes toward mental health care may be worth further attention in future investigation.

Demographic and clinical characteristics of UK military veterans attending a psychological therapies service

Aims and method To investigate the demographic and clinical characteristics of subgroups of UK veterans attending a dedicated psychological therapies service following the Improving Access to Psychological Therapies (IAPT) treatment model. Veterans accessing a newly established service in the north-west were categorised into three groups: early service leavers, those with a physical disability, and substance and/or alcohol misusers. Anxiety, depression and social functioning were measured pre- and post-treatment.

Results Veterans vary in their demographic and clinical characteristics as well as in treatment efficacy, as measured by the post-treatment scores on probable depression and anxiety. Therapy appears to be most effective in early service leavers, whereas veterans with a physical disability or a substance or alcohol misuse problem tend not to do as well in terms of symptoms of depression or anxiety.

Clinical implications This study highlights the importance of targeting different veteran subgroups for dedicated psychological therapy.

War leaves an enduring legacy in combatants' lives

The memory of combat experience endures in World War II veterans. As veterans age, traumatic memory that previously may have been suppressed in the busyness of family and everyday life can re-emerge. Combat stress may affect not only the veterans, but also those people closely associated with them. Interviews were conducted with World War II veteran aircrew, wives, children, grandchildren, siblings, and friends to examine the impact of combat experience on the veterans and the family across the life course from the perspectives of the various participants. The combat experience significantly affected the life course of most.

Attitudes to mental illness in the U.K. military: a comparison with the general population

OBJECTIVES

To compare attitudes to mental illness in the U.K. military and in the general population in England.

METHODS

Using data from a cross-sectional survey of 821 U.K. military personnel and a separate cross-sectional survey of 1,729 members of the general population in England, levels of agreement with five statements about mental illness were compared in the military and the general population.

RESULTS

The majority of respondents from both populations showed positive attitudes toward mental illness. The general population showed slightly more positive attitudes toward integrating people with mental illness into the community (68.0% [65.7%-70.1%] agreed that "People with mental illness have the same rights to a job as everyone else," vs. 56.7% [51.5%-61.7%] of the military). However, the general population showed more negative attitudes about the causes of mental illness (62.4% [60.1%-64.6%] disagreed that "One of the main causes of mental illness is a lack of self-discipline and willpower," vs. 81.3% [77.0%-84.9%] of the military).

CONCLUSIONS

Overall, attitudes toward mental illness are comparable in the general population in England and the U.K. military. Differences included the military holding more positive attitudes about the causes of mental illness, but more negatives attitudes about job rights of those with mental illness. Strategies aiming to improve attitudes toward mental illness could focus particularly on personnel's concerns around mental illness impacting on their career.

Exploring positive pathways to care for members of the UK Armed Forces receiving treatment for PTSD: a qualitative study

OBJECTIVE

To examine the factors which facilitate UK military personnel with post-traumatic stress disorder (PTSD) to engage in help-seeking behaviours.

METHODS

The study recruited active service personnel who were attending mental health services, employed a qualitative design, used semi-structured interview schedules to collect data, and explored these data using interpretative phenomenological analysis (IPA).

RESULTS

Five themes emerged about how participants were able to access help; having to reach a crisis point before accepting the need for help, overcoming feelings of shame, the importance of having an internal locus of control, finding a psychological explanation for their symptoms and having strong social support.

CONCLUSIONS

This study reported that for military personnel who accessed mental health services, there were a number of factors that supported them to do so. In particular, factors that combated internal stigma, such as being supported to develop an internal locus of control, appeared to be critical in supporting military personnel to engage in help-seeking behaviour.

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.