Skip to main content

Mental health outcomes in US and UK military personnel returning from Iraq

  • Josefin Sundin (a1), Richard K. Herrell (a2), Charles W. Hoge (a2), Nicola T. Fear (a3), Amy B. Adler (a4), Neil Greenberg (a1), Lyndon A. Riviere (a2), Jeffrey L. Thomas (a2), Simon Wessely (a3) and Paul D. Bliese (a2)...

Research of military personnel who deployed to the conflicts in Iraq or Afghanistan has suggested that there are differences in mental health outcomes between UK and US military personnel.


To compare the prevalence of post-traumatic stress disorder (PTSD), hazardous alcohol consumption, aggressive behaviour and multiple physical symptoms in US and UK military personnel deployed to Iraq.


Data were from one US (n = 1560) and one UK (n = 313) study of post-deployment military health of army personnel who had deployed to Iraq during 2007–2008. Analyses were stratified by high- and low-combat exposure.


Significant differences in combat exposure and sociodemographics were observed between US and UK personnel; controlling for these variables accounted for the difference in prevalence of PTSD, but not in the total symptom level scores. Levels of hazardous alcohol consumption (low-combat exposure: odds ratio (OR) = 0.13, 95% CI 0.07–0.21; high-combat exposure: OR = 0.23, 95% CI 0.14–0.39) and aggression (low-combat exposure: OR = 0.36, 95% CI 0.19–0.68) were significantly lower in US compared with UK personnel. There was no difference in multiple physical symptoms.


Differences in self-reported combat exposures explain most of the differences in reported prevalence of PTSD. Adjusting for self-reported combat exposures and sociodemographics did not explain differences in hazardous alcohol consumption or aggression.

Corresponding author
Nicola T. Fear, King's College London, Academic Centre for Defence Mental Health, Weston Education Centre, 10 Cutcombe Road, London SE5 9RJ, UK. Email:
Hide All

These authors contributed jointly to the work.

J.S., N.T.F., N.G. and S.W. are based at King's College London, which receives funding from the UK Ministry of Defence. US funding for this work comes from the US Army's Military Operational Medicine Research Program.

Declaration of interest

J.S., N.T.F., N.G. and S.W. 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; N.G. is employed by the UK armed forces. R.K.H., C.W.H., A.B.A., L.A.R., J.L.T. and P.D.B. are based at the Walter Reed Army Institute of Research, which is a US Department of Defense research laboratory. The views expressed here are those of the authors and do not necessarily represent the official policy or position of the US Army Medical Command or the Department of Defense.

Hide All
1 Fear, 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.
2 Hoge, 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.
3 Hoge, CW, Terhakopian, A, Castro, CA, Messer, SC, Engel, CC. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. Am J Psychiatry 2007; 164: 150–3.
4 Hoge, CW, Castro, CA. Post-traumatic stress disorder in UK and US forces deployed to Iraq. Lancet 2006; 368: 837.
5 Hotopf, 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.
6 Sundin, J, Fear, NT, Iversen, A, Rona, RJ, Wessely, S. PTSD after deployment to Iraq: conflicting rates, conflicting claims. Psychol Med 2010; 40: 367–82.
7 Smith, TC, Ryan, MAK, 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.
8 Vasterling, JJ, Proctor, SP, Friedman, MJ, Hoge, CW, Heeren, T, King, LA, et al. PTSD symptom increases in Iraq-deployed soldiers: comparison with nondeployed soldiers and associations with baseline symptoms, deployment experiences, and postdeployment stress. J Trauma Stress 2010; 23: 4151.
9 Milliken, 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.
10 Thomas, J, Wilk, J, Riviere, L, McGurk, D, Castro, C, Hoge, CW. Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Arch Gen Psychiatry 2010; 67: 614–23.
11 Rona, RJ, Hooper, R, Jones, M, Hull, L, Browne, T, Horn, O, et al. Mental health screening in armed forces before the Iraq war and prevention of subsequent psychological morbidity: follow-up study. BMJ 2006; 333: 991.
12 Mulligan, K, Fear, NT, Jones, N, Alvarez, H, Hull, L, Naumann, U, et al. Postdeployment Battlemind training for the U.K. armed forces: a cluster randomized controlled trial. J Consult Clin Psychol 2012; 80: 331–41.
13 Jacobson, IG, Ryan, MA, Hooper, TI, Smith, TC, Amoroso, PJ, Boyko, EJ, et al. Alcohol use and alcohol-related problems before and after military combat deployment. JAMA 2008; 300: 663–75.
14 Browne, T, Iversen, A, Hull, L, Workman, L, Barker, C, Horn, O, et al. How do experiences in Iraq affect alcohol use amongst male UK armed forces personnel? Occup Environ Med 2008; 65: 628–33.
15 McDevitt-Murphy, ME, Williams, JL, Bracken, KL, Fields, JA, Monahan, CJ, Murphy, JG. PTSD symptoms, hazardous drinking, and health functioning among U.S.OEF and OIF veterans presenting to primary care. J Trauma Stress 2010; 23: 108–11.
16 Wilk, JE, Bliese, PD, Kim, PY, Thomas, JL, McGurk, D, Hoge, CW. Relationship of combat experiences to alcohol misuse among U.S. soldiers returning from the Iraq war. Drug Alcohol Depend 2010; 108: 115–21.
17 Fear, NT, Iversen, A, Meltzer, H, Workman, L, Hull, L, Greenberg, N, et al. Patterns of drinking in the UK armed forces. Addiction 2007; 102: 1749–59.
18 Duma, SJ, Reger, MA, Canning, SS, McNeil, JD, Gahm, GA. Longitudinal mental health screening results among postdeployed U.S. soldiers preparing to deploy again. J Trauma Stress 2010; 23: 52–8.
19 Burnett-Zeigler, I, Ilgen, M, Valenstein, M, Zivin, K, Gorman, L, Blow, A, et al. Prevalence and correlates of alcohol misuse among returning Afghanistan and Iraq veterans. Addict Behav 2011; 36: 801–6.
20 Skopp, NA, Reger, MA, Reger, GM, Mishkind, MC, Raskind, M, Gahm, GA. The role of intimate relationships, appraisals of military service, and gender on the development of posttraumatic stress symptoms following Iraq deployment. J Trauma Stress 2011; 24: 277–86.
21 Meis, LA, Barry, RA, Kehle, SM, Erbes, CR, Polusny, MA. Relationship adjustment, PTSD symptoms, and treatment utilization among coupled National Guard soldiers deployed to Iraq. J Fam Psychol 2010; 24: 560–7.
22 MacManus, D, Dean, K, Al Bakir, M, Iversen, AC, Hull, L, Fahy, T, et al. Violent behaviour in UK military personnel returning home after deployment. Psychol Med 2011; 42: 111.
23 Kok, BC, Herrell, RK, Thomas, JL, Hoge, CW. Posttraumatic stress disorder associated with combat service in Iraq or Afghanistan: reconciling prevalence differences between studies. J Nerv Ment Dis 2012; 200: 444–50.
24 Ikin, JF, Sim, MR, Creamer, MC, Forbes, AB, McKenzie, DP, Kelsall, HL, et al. War-related psychological stressors and risk of psychological disorders in Australian veterans of the 1991 Gulf War. Br J Psychiatry 2004; 185: 116–26.
25 Adler, AB, Britt, TW, Castro, CA, McGurk, D, Bliese, PD. Effect of transition home from combat on risk-taking and health-related behaviors. J Trauma Stress 2011; 24: 381–9.
26 Warner, CH, Appenzeller, GN, Grieger, T, Belenkiy, S, Breitbach, J, Parker, J, et al. Importance of anonymity to encourage honest reporting in mental health screening after combat deployment. Arch Gen Psychiatry 2011; 68: 1065–71.
27 Fear, NT, Seddon, R, Jones, N, Greenberg, N, Wessely, S. Does anonymity increase the reporting of mental health symptoms? BMC Public Health 2012; 12: 797.
28 Weathers, F, Litz, B, Herman, D, Huska, J, Keane, T. The PTSD Checklist – Civilian Version (PCL-C). National Centre for PTSD, 1994.
29 Babor, TF, Higgins-Biddle, JC, Saunders, JB, Monteiro, MG. AUDIT: The Alcohol Use Disorders Identification Test (2nd edn). World Health Organization, 2001.
30 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV). APA, 1994.
31 Kroenke, K, Spitzer, RL, Williams, JBW. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002; 64: 258–66.
32 Unwin, 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.
33 Richardson, LK, Frueh, BC, Acierno, R. Prevalence estimates of combat-related post-traumatic stress disorder: critical review. Aust N Z J Psychiatry 2010; 44: 419.
34 Wells, TS, Miller, SC, Adler, AB, Engel, CC, Smith, TC, Fairbank, JA. Mental health impact of the Iraq and Afghanistan conflicts: a review of US research, service provision, and programmatic responses. Int Rev Psychiatry 2011; 23: 144–52.
35 Bray, RM, Pemberton, MR, Lane, ME, Hourani, LL, Mattiko, MJ, Babeu, LA. Substance use and mental health trends among U.S. military active duty personnel: key findings from the 2008 DoD Health Behavior Survey. Mil Med 2010; 175: 390–9.
36 Hawkins, EJ, Lapham, GT, Kivlahan, DR, Bradley, KA. Recognition and management of alcohol misuse in OEF/OIF and other veterans in the VA: a cross-sectional study. Drug Alcohol Depend 2010; 109: 147–53.
37 Felker, B, Hawkins, E, Dobie, D, Gutierrez, J, McFall, M. Characteristics of deployed Operation Iraqi Freedom military personnel who seek mental health care. Mil Med 2008; 173: 155–8.
38 Calhoun, PS, Elter, JR, Jones, ER, Kudler, H, Straits-Troster, K. Hazardous alcohol use and receipt of risk-reduction counseling among U.S. veterans of the wars in Iraq and Afghanistan. J Clin Psychiatry 2008; 69: 1686–93.
39 Bray, RM, Pemberton, MR, Hourani, LL, Witt, M, Olmsted, KL, Brown, JM, et al. Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. Defense Technical Information Center, 2009.
40 Ramchand, R, Miles, J, Schell, T, Jaycox, L, Marshall, GN, Tanielian, T. Prevalence and correlates of drinking behaviors among previously deployed military and matched civilian populations. Mil Psychol 2011; 23: 621.
41 Wright, KM, Foran, HM, Wood, MD, Eckford, RD, McGurk, D. Alcohol problems, aggression, and other externalizing behaviors after return from deployment: understanding the role of combat exposure, internalizing symptoms, and social environment. J Clin Psychol 2012; 68: 782800.
42 Brennen, T, Dybdahl, R, Kapidzic, A. Trauma-related and neutral false memories in war-induced posttraumatic stress disorder. Conscious Cogn 2007; 16: 877–85.
43 Koenen, KC, Stellman, SD, Dohrenwend, BP, Sommer, JF Jr, Stellman, JM. The consistency of combat exposure reporting and course of PTSD in Vietnam War veterans. J Trauma Stress 2007; 20: 313.
44 Wessely, S, Unwin, C, Hotopf, M, Hull, L, Ismail, K, Nicolaou, V, et al. Stability of recall of military hazards over time. Evidence from the Persian Gulf War of 1991. Br J Psychiatry 2003; 183: 314–22.
45 Jakupcak, M, Conybeare, D, Phelps, L, Hunt, S, Holmes, HA, Felker, B, et al. Anger, hostility, and aggression among Iraq and Afghanistan war veterans reporting PTSD and subthreshold PTSD. J Trauma Stress 2007; 20: 945–54.
46 Killgore, WD, Cotting, DI, Thomas, JL, Cox, AL, McGurk, D, Vo, AH, et al. Post-combat invincibility: violent combat experiences are associated with increased risk-taking propensity following deployment. J Psychiatr Res 2008; 42: 1112–21.
47 Rona, RJ, Hooper, R, Jones, M, Iversen, AC, Hull, L, Murphy, D, et al. The contribution of prior psychological symptoms and combat exposure to post Iraq deployment mental health in the UK military. J Trauma Stress 2009; 22: 11–9.
48 Adler, AB, Bliese, PD, McGurk, D, Hoge, CW, Castro, CA. Battlemind debriefing and battlemind training as early interventions with soldiers returning from Iraq: randomization by platoon. J Consult Clin Psychol 2009; 77: 928–40.
49 Castro, CA, Adler, AB, McGurk, D, Bliese, PD. Mental health training with soldiers four months after returning from Iraq: randomization by platoon. J Trauma Stress; 25: 376–83.
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

Sundin et al. supplementary material
Supplementary Table S1

 PDF (33 KB)
33 KB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 21 *
Loading metrics...

Abstract views

Total abstract views: 53 *
Loading metrics...

* Views captured on Cambridge Core between 3rd January 2018 - 19th March 2018. This data will be updated every 24 hours.

Mental health outcomes in US and UK military personnel returning from Iraq

  • Josefin Sundin (a1), Richard K. Herrell (a2), Charles W. Hoge (a2), Nicola T. Fear (a3), Amy B. Adler (a4), Neil Greenberg (a1), Lyndon A. Riviere (a2), Jeffrey L. Thomas (a2), Simon Wessely (a3) and Paul D. Bliese (a2)...
Submit a response


No eLetters have been published for this article.


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *