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Management of mental illness by the British Army

  • Leigh A. Neal (a1), Matthew Kiernan (a2), David Hill (a2), Frank Mcmanus (a2) and Mark A. Turner (a2)...

The Ministry of Defence has its own hospital for soldiers requiring admission for mental health problems.


To assess the efficiency of the army psychiatric hospital at restoring patients to full active duty. To assess whether a new military training and rehabilitation unit (MTRU) that emphasises military-skills training, improves outcome.


A 2-year, inception-cohort outcome study of hospital in-patients. A 12-month, case-matched, ‘before and after’ outcome study compared MTRU patients with hospital in-patients.


I (hospital in-patients, n=309): at 2-year follow-up 67 (22%) were fully fit for active duty Military psychiatrists' success rate at predicting recovery to active duty was 27%. 2: the odds of a soldier in the MTRU cohort (n=35) returning to active duty were 14 times greater than for the hospital cohort (n=35). The odds of remaining in the army while unfit for active duty were 20 times less for the MTRU than for the hospital cohort.


The army hospital is inefficient at rehabilitation to active duty. The MTRU significantly increased the odds of returning to active duty and reduced the odds of remaining in the army while still unfit. These findings may be applicable to the emergency services.

Corresponding author
Dr Leigh A. Neal, Bristol Priory Hospital, Heath House Lane, Stapleton, Bristol BS16 1EQ, UK. Tel: 01666 824410; e-mail:
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Declaration of interest

None. The views expressed in this paper are not necessarily those of the Ministry of Defence or Her Majesty's Government.

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Cook, T. D. & Campbell, D. T. (1979) Quasi-experimentation: Design and Analysis Issues for Field Settings. Boston, MA: Houghton Mifflin.
Defence Analytical Services Agency (2001) UK Armed Forces Full Time Strengths and Trained Requirements 1 Apr 01. London: Ministry of Defence.
Duchess of Kent's Psychiatric Hospital (2001) Annual Statistical Returns. Catterick Garrison: DKPH.
Gilbody, S. & Whitty, P. (2002) Improving the delivery and organisation of mental health services: beyond the conventional randomised controlled trial. British Journal of Psychiatry, 180, 1318.
Ministry of Defence (2000) PULHEEMS Administrative Pamphlet. Keynsham: MoD.
Shephard, B. (2000) A War of Nerves: Army Personnel in Psychiatry 1914–1994. London: Jonathan Cape.
World Health Organization (1992) Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD–10). Geneva: WHO.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Management of mental illness by the British Army

  • Leigh A. Neal (a1), Matthew Kiernan (a2), David Hill (a2), Frank Mcmanus (a2) and Mark A. Turner (a2)...
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Re: Management of Mental Illness by the British Army

Ian Peter Palmer, Professor of Military Psychiatry
25 July 2003

The Care of Soldiers.

Sir,It has been said that if you want to find a new idea read an old book. In this timely paper, Neal et al (2003) have successfully re-demonstrated the value of socio-cultural interventions in an Army population, where the removal of soldiers from their social milieu and psychiatric labelling in the genesis and fixation of mental illness, distress and disorder have been clearly demonstrated. Self-esteem is integral to group membership, which involves intra-group co-operation and achievement, relational comparisons with other groups, social identity and shared super-ordinate goals. Affiliation is the counterbalance to the autonomy surrendered on enlistment. It diminishes anxiety and stress and increases social support; its loss may lead to exclusion, loneliness, shame and guilt (Sarnoff, 1961. Miller, 2000) Given the mutual interdependence and trust required at times of extreme stress, where soldiers may have to rely on each other for their very existence, tolerance of disruptive behaviours is restricted, and likely to be stigmatised.

Whilst the authors draw attention to the occupational nature of Army Psychiatry, they neglect to consider the role of illness deception, which has been, and remains, a constant feature of military medical practice in all armies throughout all ages. (Carroll, 2001. Cheyne, 1827)

The authors suggest that this work may be of relevance to emergency services; I agree. I believe it may also reinforce the belief that some of us share, that tailored socio-cultural interventions are the management of choice for individuals, groups and communities afflicted with disaster and/or trauma. It may also explain why the Western Medical model of mental illness management may be less successful in cultures where the social group is more important than the individual and the altruism of such group or community membership is the healing 'intervention'.

Most cases seen in military psychiatry are psychosocial in origin and predominantly neurotic. Their assessment and management requires understanding and knowledge of their life, community, values and mores. Sadly, this paper reveals that such cultural understanding has either been absent or not acted upon.

I would urge mental health professionals to consider soldiers, in whatever Army they have served, as a unique sub-culture to be assessed and managed along the precepts of Transcultural Psychiatry.

Ian P PalmerTri-Service Professor of Defence PsychiatryRCDMFort BlockhouseGosport HantsPO12 2AR

Carroll, M.F. (2001) Deceptions In Military Psychiatry. American Journal of Forensic Psychiatry, 22(1) 53-62 Cheyne, J. (1827) 'Medical Report on the Feigned Diseases of Soldiers, in a letter addressed to George Renny, Director General of Military Hospitalsin Ireland'. Dublin Hospital Reports and Communications in Medicine and Surgery, 4, 127-128 Miller, W.I. (2000) The Mystery of Courage Harvard University Press Cambridge Mass. p179 Neal L., Kearnan, M., Hill, D., McManus, F., Turner, M. (2003) Management of Mental Illness by the British Army. British Journal of Psychiatry, 182,337-341 Sarnoff, I., Zimbardo, P.G. (1961) Anxiety, fear and social facilitation. Journal of Abnormal and Social Psychology, 62, 597-605
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Management of Mental Illness by the British Army

Maureen E Stansfield, Social Worker
11 June 2003


Management of Mental Illness by the British Army. Neal L et al.

The paper by Neal et al. describes a rehabilitation approach for mentally ill service personnel which is claimed to be effective and possibly applicable to other services. In practice, the establishment of the MTRU alongside the in-patient unit at DKPH had a negative effect on patients and staff (military and civilian) within DKPH. The concept of theMTRU was presented to staff at an open meeting shortly before commencement. Staff held reservations concerning the selection criteria for patient participation in such a unit, questioning the ethics and believing that patients were coerced into participation. Patients shared concerns with non-military staff. Many feared exclusion if their worries were shared with MTRU clinicians and that their ultimate fate would then be medical discharge from military service.

The MTRU was staffed by military nursing staff from the in-patient unit which caused an elite feel to the unit and caused unnecessary divisions in clinical staff.Within the discussion the authors suggest that patients spent less time hospitalised only informing the reader in the appendix that many were “housed” in barrack type accommodation. In reality, this “housing” was situated just off the in-patient unit in close proximity to the MTRU situated within the hospital grounds. This accommodation was also shared by serving local hospital nursing personnel. This in itself caused the management of these patients at times to be difficult and staff expressed concerns over the risks associated with this. There were concerns around which risk assessment tools were being used in the assessment process and that these were not openly shared with all clinicians. Patients reported feeling vulnerable and isolated at times. At least one patient actively considered suicide.

It was certainly not the impression of all clinical staff that the MTRU was successful. Four senior staff left employment with the MOD duringthe period discussed in the paper.

Maureen StansfieldDIPSW ASWFormer Head of Social Work serviceDKPH
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Management of mental illness by the British Army

Chris T Barker, Specialist Registrar General Adult Psychiatry
30 May 2003


There is a role for rehabilitation within military psychiatry, but I would like to raise a few concerns I have relating to the study by Neal etal.

The title itself is misleading; the British Army does not manage inpatient mental illness. They are managed in a tri-service environment, by military (Army, RAF and Navy) and non-military consultants part of a multidisciplinary team. The planned closure of the inpatient facility makes it fortunate that our main effort is community-based military psychiatry.

The classification system, known as the PULHHEEMS system (Ministry ofDefence 2000) has been incorrectly oversimplified. The general principles of this system include the statement: ‘It does not have any useful predictive value regarding the individual’s future physical performance’. Psychological factors are a part of this system.

There are a broader range of options than has been described by the authors when classifying soldiers on discharge from hospital. These classifications can be permanent or temporary. A temporary grade ‘should be seen as an indication that the soldier is expected to return to full fitness and may be awarded for a maximum total period of 12 months, .... [and] is not grounds for discrimination for consideration for promotion or employment’. Individuals who are ‘medically unfit for any form of military service’ would be medically discharged. Those ‘unfit for duty butunder medical care’ could be off sick for up to 18 months. Otherwise, evenwith various restrictions to duties, one would expect them to be usefully employed within their units. Those in barracks can have an important role in support of operations. Some are even fit to deploy in a combat zone if their role is not primarily a fighting one.

Stage one of this study is difficult to interpret using the data provided. It is not clear when those that left the service did so during the two year follow up, or whom was usefully employed or not. There are therefore implications for the cost estimate. (I am sure that those individuals who were given time and salvaged their careers are grateful, as indeed are those who promote retention.)

Stage two underestimates the selection bias. It was not possible to match for the risk assessments they received. During the year 51 individuals were admitted to the MTRU from the inpatient unit. An estimated 260 patients were admitted to the inpatient unit for the same period, yet most were considered inappropriate for the MTRU, either not referred, or were assessed as inappropriate. The control group could have contained a large number of inappropriate individuals. After one year 50% of the MTRU group had left, 57% of the control group (a larger number of the control group had left for non-medical reasons). There was also a poorcareer prognosis throughout the stage one cohort, not just those predictedto recover, with 75% having left the services at two years. This reflects the nature of inpatient military psychiatry.

Ministry of Defence (2000). AC 13371, PULHHEEMS Administrative Pamphlet. MoD.

Dr C BarkerMajor RAMCArmy Medical DirectorateCamberleySurrey
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Management of mental illness by the British Army

Melanie J Temple, Military Psychiatrist
18 May 2003


Management of Mental Illness by the British Army – Neal et al

Defence services psychiatry is a tri-service organisation in structure and service delivery and management is primarily community based. The statement that military psychiatrists ability to predict outcome is poor, is a generalisation to all military psychiatrists from those in the in-patient unit seeing the most unwell and disturbed presentations. The paper fails to mention uncontrollable factors impactingon prognosis including precipitants to admission, on-going stressors, relationship/marital problems, unhappiness with service life, and militaryspecific issues such as regiment (attitude & handling of the case by the unit), trade-group, duration of service & prior performance. These may impact on the outcome more than the illness itself. The impact of downgrading is oversimplified, indicating that the individual is un-employable whereas deployment may be the only limitation on actual work. The use of total salary in the financial implications is therefore unrepresentative of costs incurred.

There is bias in the MTRU sample. MTRU staff screened patients in and those with behavioural disturbances or substance use were actively screened out. The population presenting to the in-patient unit has a highco-morbid personality disorder and substance abuse rates. Thus the cohort entering the MTRU were less likely to have co-morbidity issues and would be expected to do better regardless of approach. Marital status is a highly significant further bias as one of commonest precipitants to admission is marital difficulty. The situation is further compounded by little matching in the control sample of factors important in prognosis given above, with resultant possible comparisons being (those in bold controlled for): MTRU - male 20-infanteer, 1-year service, single -adjustment reaction due to under confidence on first tour Vs. Control on ward – male 20-engineer, 4 years service, married - adjustment reaction & alcohol excess due towife leaving because of separation associated with army life.

The MTRU was tri-service yet the paper fails to mention the RAF and Navy personnel. The approach was unsuccessful for these personnel and their inclusion would likely change the overall findings. The authors alsocomment that individuals integrated better back into their unit yet without supportive evidence, confidence may have no bearing on acceptance and integration back into a unit.

There is also no reflection on the appropriateness and ethics of admission to the MTRU of patients, who by the nature of their diagnosis e.g. schizophrenia, will be discharged from the military. This was an areaof great contention during the pilot and one around which led to the departure of senior members of MDT staff.

“In work” occupational rehabilitation is helpful in guiding prognosis, however, it needs to be specific and cost effective to the whole population served. This study does not provide evidence that the MTRU achieves this.

Sqn Ldr M J TempleDepartment of Community PsychiatryCatterick Garrison, North Yorks
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