Mental health in the armed forces

“Medical services face a tidal wave of servicemen suffering from mental trauma as a result of the wars in Iraq and Afghanistan”, reported The Daily Telegraph . Other newspapers reporting the same study said that alcohol abuse is a bigger problem.

This news is based on a survey of nearly 10,000 personnel in the UK armed forces, which looked at whether being deployed in Iraq or Afghanistan affects mental health.

In contradiction to the Telegraph’s report, this study actually found that rates of probable post-traumatic stress disorder (PTSD) are lower than might be expected. However, it did find that regular soldiers were at a significantly higher risk of alcohol misuse. Overall, the prevalence of mental health problems in the armed forces remained stable between 2003 and 2009 despite increasing deployment in foreign combat zones.

Though the low rates of PTSD are reassuring, the high-rates of alcohol misuse are more cause for concern. The researchers say that new alcohol policies have recently been introduced by all three services, but their effects have yet to be assessed. They suggest that any reduction in alcohol misuse among UK troops will need a fundamental change in attitudes, since within British military culture alcohol is seen as “aiding social interaction and unit cohesion”.

Where did the story come from?

The study was carried out by researchers at the Academic Centre for Defence Mental Health and the King’s Centre for Military Health Research and Biostatistics, and the Institute of Psychiatry, King’s College London. It was funded by the UK Ministry of Defence and published in the peer-reviewed journal The Lancet.

The coverage of the story in the media was generally fair, with most correctly reporting that alcohol is a problem for troops returning from combat zones. The BBC pointed out that mental trauma rates have remained low. However, the Telegraph’s headline about a “tidal wave” of mental trauma was taken from some predictions of a “so-called tidal wave” discussed in the study, rather than its actual findings.

What kind of research was this?

This large cohort study assessed the effects of deployment to Iraq and Afghanistan on the mental health of the UK armed forces from 2003 to 2009. It follows a previous study by the same researchers, published in 2006, which looked at the health of UK military personnel deployed in the Iraq war. The earlier study found that involvement in Iraq did not affect the mental health of regulars, although reservists (individuals, usually with civilian jobs, who are occasionally paid to undertake military duties) suffered higher rates of depression and anxiety than regular troops.

For the new study, researchers re-assessed the mental health of those who were in the earlier study, and they included two additional groups – those who joined the military since 2003 and those deployed to Afghanistan between April 2006 and April 2007. Using randomly selected samples from all three groups, they looked at how deployment to Iraq and Afghanistan affected mental health. They also looked at the effect of multiple deployments, and whether these effects increased or diminished over time after returning from a tour of duty.

What did the research involve?

Researchers identified 17,812 potential study participants in the Royal Navy, the British Army and the Royal Air Force, using information provided by the MoD. Steps were taken to ensure that this sample was representative of the entire UK military in terms of age, rank distribution and type of engagement.

Potential participants were sent questionnaires and a letter explaining the study. Those who did not respond were also visited by researchers who went to more than 100 military units across the UK, Germany and Cyprus. Further steps were taken to trace people who did not respond to a second mailing.

The questionnaire asked about people’s age, sex, marital status and education. It also asked about their service history, life since leaving the services, their most recent deployment experiences in Iraq and Afghanistan, and their mental and physical health. The deployment sections included questions about the kind of roles people had during deployment, the welfare support they had received, difficulties their families might have had, and adjusting to being back at home.

They were also asked about their military experiences, for example, encountering sniper fire or seeing personnel wounded or killed. Participants were also asked to rate their own general and mental health and alcohol use, with questions based on well-known health questionnaires and checklists.

Researchers combined the samples from all three groups given a questionnaire, and analysed the association between deployment experiences and mental health.

What were the basic results?

Of those sent the questionnaire, 9,990 (56%) participants completed the study questionnaire (83% of these were regulars rather than reservists).

The main findings were:

• Probable post-traumatic stress disorder was reported by 376 people, 4% of the total sample (95% confidence interval [CI] 3.5 to 4.5).
• Reportedly, 19.7% had experienced other common mental disorders (95% CI 18.7 to 20.6).
• Alcohol misuse was reported by 1,323 people, 13.0% (95%CI 12.2 to 13.8).
• Regulars deployed to Iraq or Afghanistan were significantly more likely to report alcohol misuse than those not deployed.
• Reservists were more likely to report probable post-traumatic stress disorder than those not deployed.
• Regular personnel in combat roles were more likely than were those in support roles to report probable post-traumatic stress disorder.
• There was no association with number of deployments for any outcome.

How did the researchers interpret the results?

The researchers say that the symptoms of common mental disorders and alcohol misuse remain the most frequently reported mental disorders among UK armed forces personnel.

They note that the prevalence of probable post-traumatic stress disorder was low, and they call for continued health surveillance of UK military personnel.

Conclusion

This is a well-conducted survey using established methods that were clearly described in detail.

There are several points to note about this survey:

• The researchers admit that only a limited number of people who were invited were willing to participate in the survey. They say that younger people and those of lower rank were less likely to take part. As this could have potentially skewed the results, the researchers say they used standard statistical techniques to take this imbalance into account.
• They say that the prevalence of post-traumatic stress disorder is often overestimated based on self-reported questions compared with clinical interviews. As such, even the low prevalence of post-traumatic stress disorder reported here is likely to be an overestimate.

One reassuring finding of this study is that rates of probable post-traumatic stress disorder are lower than might be expected. The high-rates of alcohol misuse is more cause for concern. The researchers say this is perhaps unsurprising given the predominance of young men in the military. Yet even when this factor was taken into account, levels of alcohol misuse overall were substantially higher than in the general population.

The researchers say that new alcohol policies have recently been introduced by all three services, but their effects have yet to be assessed. They suggest that any reduction in alcohol misuse among UK troops will need a fundamental change in attitudes, since within British military culture alcohol is seen as “aiding social interaction and unit cohesion”.