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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.
Abstract
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.

Aims

We 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.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), 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: sharon.stevelink@kcl.ac.uk
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These authors are joint last authors.

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References
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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.
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eLetters

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.

References

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.

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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.

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