Skip to main content

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

  • Sharon A. M. Stevelink (a1), Margaret Jones (a2), Lisa Hull (a3), David Pernet (a4), Shirlee MacCrimmon (a4), Laura Goodwin (a5), Deirdre MacManus (a6), Dominic Murphy (a6), Norman Jones (a7), Neil Greenberg (a8), Roberto J. Rona (a9), Nicola T. Fear (a10) and Simon Wessely (a11)...
  • Please note a correction has been issued for this article.

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.


We examined the prevalence of mental disorders and alcohol misuse, whether this differed between serving and ex-serving regular personnel and by deployment status.


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.


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.


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.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Mental health outcomes at the end of the British involvement in the Iraq and Afghanistan conflicts: a cohort study
      Available formats
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Mental health outcomes at the end of the British involvement in the Iraq and Afghanistan conflicts: a cohort study
      Available formats
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Mental health outcomes at the end of the British involvement in the Iraq and Afghanistan conflicts: a cohort study
      Available formats
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Correspondence: Sharon Stevelink, King's Centre for Military Health Research, King's College London, Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK. Email:
Hide All

These authors are joint last authors.

Hide All
1UK Ministry of Defence. Number of Personnel that Deployed to Iraq and Afghanistan. MoD, 2014 (
2Chilcot, J, Freedman, L, Lyne, R, Prashar, U. The Report of the Iraq Inquiry - The Executive Summary. Report of a Committee of Privy Counsellors, 2016.
3House of Commons. Operations in Afghanistan: Fourth Report of Session 2010–2012. TSO, 2011.
4Fear, NT, Jones, M, Murphy, D, Hull, L, Iversen, AC, Coker, B, et al. What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces? A cohort study. Lancet 2010; 375: 1783–97.
5Hotopf, M, Hull, L, Fear, NT, Browne, T, Horn, O, Iversen, A, et al. The health of UK military personnel who deployed to the 2003 Iraq war: a cohort study. Lancet 2006; 367: 1731–41.
6Centers for Disease Control. Health status of Vietnam veterans. I. Psychosocial characteristics. The Centers for Disease Control Vietnam Experience Study. JAMA 1988; 259: 2701–7.
7Dohrenwend, BP, Turner, JB, Turse, NA, Adams, BG, Koenen, KC, Marshall, R. The psychological risks of Vietnam for U.S. veterans: a revisit with new data and methods. Science 2006; 313: 979–82.
8Marmar, CR, Schlenger, W, Henn-Haase, C, Qian, M, Purchia, E, Li, M, et al. Course of posttraumatic stress disorder 40 years after the Vietnam War: findings from the National Vietnam Veterans Longitudinal Study. JAMA Psychiatry 2015; 72: 875–81.
9Wessely, S, Jones, E. Psychiatry and the ‘lessons of Vietnam’: what were they, and are they still relevant? War Soc 2004; 22: 89103.
10UK Ministry of Defence. UK Armed Forces Monthly Service Personnel Statistics. Defence Statistics (Tri Service), 2017.
11Iversen, A, Nikolaou, V, Greenberg, N, Unwin, C, Hull, L, Hotopf, M, et al. What happens to British veterans when they leave the armed forces? Eur J Public Health 2005; 15: 175–84.
12Forces in Mind Study.The Transition Mapping Study: Understanding the Transition Process for Service Personnel Returning to Civilian Life. Forces in Mind Study,2013 (
13National Audit Office. Leaving the Services. NAO, 2007.
14Iversen, A, Dyson, C, Smith, N, Greenberg, N, Walwyn, R, Unwin, C, et al. Goodbye and good luck: the mental health needs and treatment experiences of British ex-service personnel. Br J Psychiatry 2005; 186: 480–96.
15Hatch, SL, Harvey, SB, Dandeker, C, Burdett, H, Greenberg, N, Fear, NT, et al. Life in and after the Armed Forces: social networks and mental health in the UK military. Soc Health Illness 2013; 35: 1045–64.
16Unwin, C, Blatchley, N, Coker, W, Ferry, S, Hotopf, M, Hull, L, et al. Health of UK servicemen who served in Persian Gulf War. Lancet 1999; 353: 169–78.
17Goldberg, DP, Gater, R, Sartorius, N, Ustun, TB, Piccinelli, M, Gureje, O, et al. The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychol Med 1997; 27: 191–7.
18Blanchard, EB, Jones-Alexander, J, Buckley, TC, Forneris, CA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther 1996; 34: 669–73.
19Babor, TF, Higgins-Biddle, JC, Saunders, JB, Monteiro, MG. AUDIT. The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care. Department of Mental Health and Substance Dependence, World Health Organization, 2001.
20Spitzer, RL, Kroenke, K, Williams, JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 1999; 282: 1737–44.
21Sundin, J, Herrell, RK, Hoge, CW, Fear, NT, Adler, AB, Greenberg, N, et al. Mental health outcomes in US and UK military personnel returning from Iraq. Br J Psychiatry 2014; 204: 200–7.
22Morton, LM, Cahill, J, Hartge, P. Reporting participation in epidemiologic studies: a survey of practice. Am J Epidemiol 2006; 163: 197203.
23Ryan, MA, Smith, TC, Smith, B, Amoroso, P, Boyko, EJ, Gray, GC, et al. Millennium Cohort: enrollment begins a 21-year contribution to understanding the impact of military service. J Clin Epidemiol 2007; 60: 181–91.
24Tanielian, T, Jaycox, LH. Prevalence of PTSD, depression, and TBI among returning servicemembers. In Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery (eds Tanielian, T and Jaycox, LH): 3582. RAND Corporation, 2008.
25Hoge, CW, Lesikar, SE, Guevara, R, Lange, J, Brundage, JF, Engel, CC Jr, et al. Mental disorders among U.S. military personnel in the 1990s: association with high levels of health care utilization and early military attrition. Am J Psychiatry 2002; 159: 1576–83.
26Hunt, EJF, Wessely, S, Jones, N, Rona, RJ, Greenberg, N. The mental health of the UK Armed Forces: where facts meet fiction. Eur J Psychotraumatol 2014; 5: 23617.
27Hoge, CW, Auchterlonie, JL, Milliken, CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 2006; 295: 1023–32.
28Hoge, CW, Castro, CA, Messer, SC, McGurk, D, Cotting, DI, Koffman, RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351: 1322.
29Xue, C, Ge, Y, Tang, B, Liu, Y, Kang, P, Wang, M, et al. A meta-analysis of risk factors for combat-related PTSD among military personnel and veterans. PLoS One 2015; 10: e0120270.
30Brewin, CR, Andrews, B, Valentine, JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol 2000; 68: 748–66.
31Oster, C, Morello, A, Venning, A, Redpath, P, Lawn, S. The health and wellbeing needs of veterans: a rapid review. BMC Psychiatry 2017; 17: 414.
32Iversen, AC, van Staden, L, Hughes, JH, Greenberg, N, Hotopf, M, Rona, RJ, et al. The stigma of mental health problems and other barriers to care in the UK Armed Forces. BMC Health Serv Res 2011; 11: 31.
33Coleman, SJ, Stevelink, SAM, Hatch, SL, Denny, JA, Greenberg, N. Stigma-related barriers and facilitators to help seeking for mental health issues in the armed forces: a systematic review and thematic synthesis of qualitative literature. Psychol Med 2017; 47: 1880–92.
34Wilson, J, Jones, M, Fear, NT, Hull, L, Hotopf, M, Wessely, S, et al. Is previous psychological health associated with the likelihood of Iraq War deployment? An investigation of the‘healthy warrior effect’. Am J Epidemiol 2009; 169: 1362–9.
35Rona, RJ, Fear, NT, Hull, L, Greenberg, N, Earnshaw, M, Hotopf, M, et al. Mental health consequences of overstretch in the UK armed forces: first phase of a cohort study. BMJ 2007; 335: 603.
36Rona, RJ, Jones, M, Keeling, M, Hull, L, Wessely, S, Fear, NT. Mental health consequences of overstretch in the UK Armed Forces, 2007–09: a population-based cohort study. Lancet Psychiatry 2014; 1: 531–8.
37Harvey, SB, Hatch, SL, Jones, M, Hull, L, Jones, N, Greenberg, N, et al. The long-term consequences of military deployment: a 5-year cohort study of United kingdom reservists deployed to Iraq in 2003. Am J Epidemiol 2012; 176: 1177–84.
38Office for National Statistics. Adult Drinking Habits in Great Britain: 2005 to 2016. Office for National Statistics, 2017.
39The Information Centre for Health and Social Care. Adult Psychiatric Morbidity in England, 2007: results of a Household Survey. NHS Digital, 2009.
40Milliken, CS, Auchterlonie, JL, Hoge, CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA 2007; 298: 2141–8.
41Smith, TC, Ryan, MA, Wingard, DL, Slymen, DJ, Sallis, JF, Kritz-Silverstein, D. New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study. BMJ 2008; 336: 366–71.
42Vasterling, JJ, Aslan, M, Proctor, SP, Ko, J, Marx, BP, Jakupcak, M, et al. Longitudinal examination of posttraumatic stress disorder as a long-term outcome of Iraq War deployment. Am J Epidemiol 2016; 184: 796805.
43The Information Centre for Health and Social Care. Mental Health and Wellbeing in England: Adult Psychiatric Morbidity Survey 2014. NHS Digital, 2016.
44Rona, RJ, Fear, NT, Hull, L, Wessely, S. Women in novel occupational roles: mental health trends in the UK Armed Forces. Intern J Epidemiol 2007; 36: 319–26.
45Woodhead, C, Wessely, S, Jones, N, Fear, NT, Hatch, SL. Impact of exposure to combat during deployment to Iraq and Afghanistan on mental health by gender. Psychol Med 2012; 42: 1985–96.
46UK Ministry of Defence. Defence People Mental Health and Wellbeing Strategy 2017–2022. MoD, 2017.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Type Description Title
Supplementary materials

Stevelink et al. supplementary material
Stevelink et al. supplementary material 1

 Unknown (94 KB)
94 KB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

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

  • Sharon A. M. Stevelink (a1), Margaret Jones (a2), Lisa Hull (a3), David Pernet (a4), Shirlee MacCrimmon (a4), Laura Goodwin (a5), Deirdre MacManus (a6), Dominic Murphy (a6), Norman Jones (a7), Neil Greenberg (a8), Roberto J. Rona (a9), Nicola T. Fear (a10) and Simon Wessely (a11)...
  • Please note a correction has been issued for this article.
Submit a response


Threats to the validity of studies of PTSD from unmeasured symptomatic exposure to mefloquine

Remington Nevin, Executive Director, The Quinism Foundation
13 November 2018

I read with interest the recent study by Stevelink and colleagues, [1] which studied the prevalence of various mental health outcomes, including post-traumatic stress disorder (PTSD), among UK military personnel following the conflicts in Iraq and Afghanistan. I am concerned that several of the authors' conclusions may be invalid, owing to a failure to measure and control for an important confounder in their study.

Subjects in the authors’ study were at risk of exposure to mefloquine, an antimalarial drug widely used by the UK military during the period, particularly during training missions in Africa and during deployments to Afghanistan.

Mefloquine is known to cause psychiatric adverse effects, including nightmares, insomnia, depression, and anxiety, which can last years after use. Individuals who experience psychiatric adverse effects during continued use of the drug, a condition known as symptomatic exposure, are at risk of these adverse effects becoming chronic. For example, based on a synthesis of recent data, abnormal dreams and nightmares lasting over three years after use of mefloquine may affect over 2% of those exposed to the drug. [2]

Various U.S. military authors have cautioned that mefloquine use can “confound the diagnosis and management of PTSD”, [3] and that given “the overlapping symptoms of post-traumatic stress disorder and mefloquine toxicity, it can be challenging to distinguish between the two diagnoses”. [4] The importance of identifying past mefloquine exposure is further unscored by the addition of Criterion H to the PTSD diagnostic criteria in the DSM-5, which requires that the disturbance not be due to the effects of a medication. [5] As the chronic adverse effects of mefloquine may mimic several symptoms of PTSD, including several symptoms assessed using the 17-item National Centre for PTSD Checklist (PCL-C), the authors use of this instrument without distinguishing which symptoms may have been due to mefloquine risks the adverse effects of the drug having been misattributed to PTSD.

As mefloquine exposure is correlated with deployment, and as symptomatic mefloquine exposure creates a separate causal pathway for the development of several symptoms assessed by the PCL-C, symptomatic mefloquine exposure serves as a classic epidemiological confounder in the authors’ study. [2] In order to avoid potentially fatal threats to validity that result from such confounding, the authors are encouraged to measure symptomatic mefloquine exposure in future studies and to control for these effects during analysis. Our group has introduced the 2-question White River Mefloquine Instrument (WRMI-2) for this purpose and encourages the use of this instrument in research and in the clinical evaluation of recent veterans at risk of mefloquine exposure.


1. Stevelink SAM, Jones M, Hull L, Pernet D, MacCrimmon S, Goodwin L, et al. Mental health outcomes at the end of the British involvement in the Iraq and Afghanistan conflicts: a cohort study. Br J Psychiatry 2018. doi:10.1192/bjp.2018.175.

2. Nevin RL. Re: ‘A Decade Of War: Prospective Trajectories of Posttraumatic Stress Disorder Symptoms Among Deployed US Military Personnel and the Influence of Combat Exposure’. Am J Epidemiol 2018; 187: 1573–4.

3. Magill A, Cersovsky S, DeFraites R. Special Considerations for US Military Deployments. In CDC Health Information for International Travel: The Yellow Book 2012. (ed GW Brunette): 561–5. Oxford University Press, 2012.

4. Livezey J, Oliver T, Cantilena L. Prolonged Neuropsychiatric Symptoms in a Military Service Member Exposed to Mefloquine. Drug Safety - Case Reports 2016; 3: 7.

5. Nevin RL. Mefloquine and Posttraumatic Stress Disorder. In Textbook of Military Medicine. Forensic and Ethical Issues in Military Behavioral Health. (ed EC Ritchie): 277–96. Borden Institute, 2015.

... More

Conflict of interest: I have been retained as consultant and expert witness in legal cases involving claims of adverse effects from antimalarial drugs, including mefloquine.

Write a reply


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *