In a recent paper, Hoge et al (Reference Hoge, Castro and Messer2004) reported that US personnel who were deployed to Iraq reported poorer mental health after the campaign than before (Reference SpurgeonSpurgeon, 2004). Their results were taken from cross-sectional surveys before and after deployment. We performed a brief longitudinal mental health screen of members of the UK's Air Assault Brigade before and after deployment to Iraq last year. In this paper we report our preliminary findings.
Of a possible 899 soldiers, 733 participated in this survey (82% of the available population, compared with 58% for Reference Hoge, Castro and MesserHoge et al, 2004). The brigade commander supported the project; individuals participated voluntarily and gave signed consent. The protocol was approved by the Defence Medical Services Clinical Research Committee.
Questionnaires were circulated at the end of pre-deployment mental health briefings (standard in UK units' preparations for operational deployments). Soldiers were informed that military mental health practitioners would contact them confidentially if results revealed cause for concern. Participants were told that commanders would be informed only about pooled results.
The ages of responders ranged from 17 to 48 years and 71 of the entire sample (8%) were female. The sample was surveyed before deployment using the General Health Questionnaire (GHQ-28) (Reference Goldberg and HillierGoldberg & Hillier, 1979). All those with scores exceeding 20 (n=16) were contacted and offered support.
After war-fighting operations were complete, personnel returned to the UK having been in theatre for approximately 4 months.
Questionnaires, which included the GHQ-28 and the Trauma Screening Questionnaire (TSQ; Reference Brewin, Rose and AndrewsBrewin et al, 2002), were then sent to participants. One month after return, 421 of the original sample of 899 completed the questionnaires. The sample size was lower than before deployment (as with Reference Hoge, Castro and MesserHoge et al, 2004) because many personnel had been redeployed or were on leave. (It is highly unlikely that this loss to follow-up was attributable to illness as very few diagnoses of post-traumatic stress disorder were eventually made across all three branches of the British Armed Forces following the Iraq deployment.)
Non-responders did not differ from responders on pre-deployment measures (t=71.01, P=0.31). The mean score on the GHQ-28 was 1.94. Results showed that 2% (n=9) exceeded cut-off criteria on the TSQ (contrasting with 12% reported by Hoge et al), with a further two soldiers scoring over 20 on the GHQ-28. All were contacted individually and offered support.
Overall, 35% of the original sample (n=254) completed both sets of questionnaires. The high turnover of personnel observed between the two occasions was a combined result of postings to new units, redeployment, leave and attendance at training courses. Also, participation at both stages was voluntary. In addition, whereas the first set of questionnaires was administered during routine pre-deployment training, the follow-up questionnaires were administered internally on a sub-unit basis, which may have contributed to the reduced follow-up sample size. It is not, however, believed that the reasons for the reduced sample size would have affected validity.
Analysis of the GHQ-28 scores before and after deployment revealed a highly significant (t=3.15, P<0.005) relative improvement in mental health. This was indicated by lower GHQ-28 scores which showed a mean difference of 0.93 (95% CI 0.35-1.52). These findings raise the question of whether military deployment is necessarily bad for psychological health.
The principal finding of this preliminary study was a lack of deterioration in the mental health of British soldiers deployed to Iraq. This is in contrast to the recent well-publicised findings of Hoge et al (Reference Hoge, Castro and Messer2004). Why do our results differ? The units studied by Hoge et al and ourselves were all front-line units with reputations for military competence. Our measures were administered 1 month after return whereas those used by Hoge et al were administered 3-4 months after return from theatre. However, post-deployment associated psychological distress is likely to reduce over time (Reference Greenberg, Maingay and IversenGreenberg et al, 2003), rather than the converse. It is recognised, however, that we did not at that time have any baseline prevalence measures using the GHQ with British Armed Forces against which these results might be compared. Also, whereas we used different measures to Hoge et al, we think it implausible that this would account for the considerable differences. A final factor might be the different areas of the country in which British and US troops were deployed and the differences in fighting in which they were involved, reflected in the higher number of US casualties, both physical and psychological.
Our results show that it is premature to conclude that the Iraq war has already had a serious adverse effect on the mental health of the armed forces, or that we are inevitably facing a repeat of the Vietnam story (Wessely & Jones, 2004). This study also reminds us that where there are highly selected forces with high morale involved in focused operations with positive outcomes, whatever the immediate political context, participation in war fighting may sometimes not necessarily be as deleterious to psychological well-being as has previously been thought.
We thank Stewart Neale, RMN, Community Psychiatric Nurse, and Michael Srinivasan, MRCPsych, Consultant Psychiatrist, Department of Community Mental Health, 16 Air Assault Brigade and Colchester Garrison.