Why is the mental health of veterans important?

Literature from the USA on the Second World War has suggested that for most people military service had a positive effect on their life trajectory. Studies of men who served during the Second World War demonstrated that after leaving the armed forces, veteran status afforded these individuals greater educational opportunities, better qualifications, higher employment rates and bigger wage packets, partly because of the generous provision of the G.I. Bill of 1944 (US Department of Veterans Affairs 2008). In Germany, although those who fought in the Second World War initially had unfavourable occupational outcomes, these effects diminished rapidly over time as the German economy started to recover (Reference Dandeker, Wessely and IversenDandeker 2003). However, some of those who returned from the Vietnam War did not fare so well. The literature suggests that a proportion of veterans returning from the Vietnam War to civilian life were disadvantaged in terms of earnings, jobs and educational attainment. This disadvantage was most acute for those with mental health problems (Reference Anderson and MitchellAnderson 1992). Veterans with PTSD often ended up with lower salaries, more enduring drug and alcohol problems, and a higher chance of ending up in prison (Reference Dandeker, Wessely and IversenDandeker 2003).

The US literature concerning those returning from the 1991 Gulf War has been no more encouraging, particularly for those who returned from combat unwell. Such individuals were more likely to be unemployed or to lose their job, to end up within the prison system and to be alcohol dependent. This is despite the fact that the land combat phase of the Gulf War lasted less than 100 h and was substantially less intense than more recent operations in Iraq and Afghanistan (Reference Dandeker, Wessely and IversenDandeker 2003).

In the military population (theatre-specific studies aside), those with mental health problems are more likely to leave service prematurely (Reference Hoge, Lesikar and GuevaraHoge 2002), experience lost work days (Reference Engel, Ursano and MagruderEngel 1999) and to end up socially excluded (e.g. homeless) (Reference Rosenheck, Frisman and ChungRosenheck 1994). In the UK, despite the press focus on negative outcomes for war veterans, the limited existing evidence suggests that the majority do well after leaving the armed forces. A few years ago we were involved in a study that examined longitudinal outcomes for a cohort of service leavers from a large randomly selected military cohort; 87.5% of those who left were in full-time employment (Reference Iversen, Nikolaou and GreenbergIversen 2005a). Deployment to the 1991 Gulf War did not disadvantage veterans in terms of employment; in fact, those who returned in good health from their Gulf service had a greater chance of being employed than those who had not been deployed there. This is not an uncommon phenomenon and has been called the ‘medal effect’ of a tour of duty. However, those who experienced mental health problems on their return were more likely to leave the military and to be unemployed after leaving. Veterans' symptoms appeared to remain fairly stable and persistent after leaving the armed forces. Taken together, these results suggest that there is a small but important minority of veterans who leave the services with mental health problems, remain chronically unwell and are vulnerable to social exclusion (e.g. marital breakdown, unemployment, homelessness).

Common mental health problems in veterans

Large-scale studies of veterans of the 1991 Gulf War have found that the most common mental health problems are depression, anxiety disorders and alcohol misuse/dependence (Reference Ismail, Kent and BrughaIsmail 2002; Reference Ikin, Sim and CreamerIkin 2004; Reference Toomey, Kang and KarlinskyToomey 2007). A small cross-sectional study in the UK of Gulf, Bosnia and ‘Era’ (personnel who served in the military at the same time but were not deployed on these operations) veterans who had all left the military revealed the same findings (Reference Iversen, Dyson and SmithIversen 2005b). This is mirrored in both the still-serving US military population (Reference Riddle, Smith and SmithRiddle 2007) and in the UK general population (Reference Jenkins, Lewis and BebbingtonJenkins 1997). A similar range of disorders has been reported in large US samples of the military population. Reference Hoge, Lesikar and GuevaraHoge and colleagues (2002) examined the range of disorders accounting for hospital admissions and out-patient visits in the US military. Alcohol and substance misuse, adjustment disorders, mood disorders and personality disorders were the most common diagnoses, with PTSD accounting for only 2% of out-patient visits and 1% of admissions. Reference Riddle, Smith and SmithRiddle and colleagues (2007) reported that the most common disorders in a representative sample of the US military were alcohol dependence and depression. The findings of these studies (Box 1) are at odds with the focus given to PTSD in the press. Reasons for this are explored below.

Why is there such a focus on post-combat PTSD?

The USA's experiences of service personnel returning unwell from the Vietnam War have shaped the landscape of traumatology for the past 30 years, and indeed were responsible for the introduction of the term ‘post-traumatic stress disorder’ into the Diagnostic and Statistical Manual of Mental Disorders in 1980 (Reference MarloweMarlowe 2000). Despite the fact that historians have described the Vietnam War as ‘low intensity’ for US armed forces (Reference Jones and WesselyJones 2001), the most influential congressionally mandated outcome study, the National Vietnam Veterans Readjustment Study (NVVRS), found a lifetime prevalence of 30.9% and a current prevalence of 15.2% for PTSD (Reference Kulka, Schlenger and FairbankKulka 1990). This seems a curious finding given that other commentators report that about 85% of Vietnam veterans returned to productive, reasonably well-adjusted lives after the war (Reference Burkett and WhitleyBurkett 1998), and some informal sources suggest that 74% of veterans, given the chance, would ‘do it all again’ (Vietnam Helicopter Flight Crew Network 2008). The NVVRS findings were also in contrast to the Centre for Disease Control's Vietnam Experience Study, which reported rates of 14.7% for lifetime PTSD and 2.2% for current PTSD 12 years after the Vietnam War ended (Centre for Disease Control Vietnam Experience Study Group 1988). Claims that these results are not congruent with the numbers of combat troops in Vietnam and claims and counterclaims about their occupational adjustment continue to excite controversy, as witnessed by a heated debate in the Journal of Traumatic Stress in August 2007. Recent re-examination of the NVVRS taking account of functional impairment associated with PTSD symptoms has re-calculated the rates as 18.7% for lifetime prevalence and 15.2% 12 years after the war (Reference Dohrenwend, Turner and TurseDohrenwend 2006). Moreover, the trajectory for most veterans, even those with the most severe symptoms, was towards improvement in symptoms or remission.

Despite these findings, US military veterans' claims for PTSD have increased from 120 265 in 1999 to 215 871 in 2004, with total payments rising from US$1.72 billion to US$4.28 billion in the same period. Many of the claimants are Vietnam veterans claiming for ‘delayed’ PTSD. This situation has led the Committee on Veterans Compensation for Posttraumatic Stress Disorder (2007) to describe PTSD in veterans as a ‘significant public health problem’. Among veterans seeking mental health treatment in Veterans Administration clinics, most (up to 94%) concurrently apply for PTSD disability benefits.

It is clear that further research is needed to refine our understanding of the individual factors that contribute to symptom chronicity and ongoing functional impairment in order that we may identify, and target services towards, the most vulnerable of combat returnees who have PTSD symptoms.

What will the burden of mental disorders be like from the Iraq War?

Many people in the USA, including the former President George W. Bush, have made reference to the similarities between the current conflict in Iraq and that in Vietnam (both are wars without fronts where it is difficult for soldiers to distinguish friend from foe among the civilian population).

‘The New Vietnam’ has commentators predicting a deluge of troubled soldiers from the current conflict. Studies from the USA to date have indeed revealed that there appears to be a substantial burden of mental health problems associated with the recent conflicts in Iraq and Afghanistan. Reference Hoge, Castro and MesserHoge and colleagues (2004) conducted an anonymous survey of combatants before deployment and again 3–4 months after returning from deployment to Iraq or Afghanistan. Those who had completed a tour of duty in Iraq had significantly higher rates of major depression, generalised anxiety disorder and PTSD than those who had been deployed to Afghanistan. Furthermore, rates were higher than those seen before deployment to Iraq. Background rates of PTSD in the US military appear to be higher than in the UK armed forces. The authors also report that 9.3% of the US military fulfilled the diagnostic criteria for PTSD prior to deployment to Iraq and this rose to 17.1% on return (compared with 7% in UK combat troops using an identical measure).

Larger-scale studies have confirmed that there are differences in the rate of mental illness in US troops compared with UK troops. For example, a study based on routine post-appointment health assessment of US service personnel returning from deployment screened survey responses from 16 000 returnees from Afghanistan and 222 000 returnees from Iraq (Reference Hoge, Auchterlonie and MillikenHoge 2006). The prevalence of mental health problems was 19.1% among those returning from Iraq, compared with 11.3% in those returning from Afghanistan and 8.5% in returnees from other locations. Mental health problems reported on the post-deployment assessment were significantly associated with combat experiences, mental healthcare referral and utilisation, and attrition from military service. The reasons for the difference between the US and UK rates of PTSD post-combat are a matter of ongoing discussion, but it is likely that they relate to differences in combat exposure, length of tour (the US military have deployed their soldiers in the field for almost twice as long as their European allies since the First World War) and in the age of the combatants deployed by the respective countries.

Between January and June 2003, 66 000 British service personnel were deployed in the Persian Gulf. Between 18 January and 28 April 2003, 48 000 took part in the first stage of hostilities in Iraq (hereafter referred to as Operation Telic 1). Since that time, British service personnel have continued to be deployed in Iraq in increasingly arduous operations. Although the ‘war-fighting’ period has officially ended, it is well recognised that deployments have become increasingly difficult and dangerous because of insurgency and sectarian violence. At the time of writing, coalition forces' casualties to date were numbered at 4544 people, 178 of whom are British. At present, the majority of those who have served in Iraq are still-serving personnel, and therefore the burden of mental health problems for veterans of the Iraq conflict remains unclear. Combat Stress, a leading service charity in the UK, reported a fourfold increase in referrals of ex-service personnel between 2005 and 2007, 283 of whom served in Iraq or Afghanistan, although without a denominator such data are always difficult to interpret (Combat Stress, personal communication 2007).

Risk of psychiatric injury for reservists

There are approximately 36 000 volunteer reservists in the UK at present. The largest of the UK's reserve services is the army, a quarter of the total strength of which is contributed by the Territorial Army. The Iraq War necessitated the first compulsory call-up of reservists from all three armed services since the Korean War in the 1950s, with 12 580 mobilised.

Risk factors for mental health disorders in veterans

Reference Riddle, Smith and SmithRiddle and colleagues (2007) examined the baseline prevalence of mental disorders in the US military in a cohort of 77 047 participants and found that certain military subpopulations, including female, younger, less educated, single, White, short-term service enlisted personnel, and army personnel, were more likely to have poor mental health. In the UK veteran population, a similar, although smaller (n = 496), study found that those who served in the army, were single, and were from lower ranks were most at risk of reporting mental health problems (Reference Iversen, Dyson and SmithIversen 2005b). Studies from both the UK and the USA have shown that combatants who had pre-enlistment/childhood adversity were more likely to experience mental health problems on return from deployment (Reference Cabrera, Hoge and BlieseCabrera 2007; Reference Iversen, Fear and SimonoffIversen 2007).

Improving the mental health of ex-service personnel and reservists

In 2001, King's College London performed a scoping study to look at the mental health needs of veterans and how they were currently being met (Reference Dandeker, Wessely and IversenDandeker 2003). A clear view that emerged from the stakeholders and veterans interviewed was that the mental health needs of veterans were not being met by existing National Health Service (NHS) provisions at that time. A more recent cross-sectional study examining health service utilisation in those who have left the British armed forces (Reference Iversen, Dyson and SmithIversen 2005b) has confirmed the anecdotal impression. It found that only 58% of those who reported mental health problems were currently seeking help from any professional, and only 28% had sought help from a non-governmental organisation. Of those who had sought help, the majority were being cared for within primary care and only 28% had been seen in secondary care. Just 7% had received support from a community psychiatric nurse and only 4% had been offered cognitive–behavioural therapy, despite its recommendation by the National Institute for Health and Clinical Excellence as an effective treatment for depression and PTSD (National Collaborating Centre for Mental Health 2005). Similarly, only 23–40% of US ex-combatants who had returned from operational duties with mental health problems had sought mental healthcare (Reference Hoge, Auchterlonie and MillikenHoge 2006). Those with mental health problems were much more likely to report barriers to care and concerns about stigmatisation than those who were well (Reference Hoge, Castro and MesserHoge 2004). In a study in the Royal Navy, distressed service personnel reported self-stigmatising beliefs two to three times more often than those who were not distressed (Reference Langston, Greenberg and FearLangston 2009). Individuals with stress were also more sensitive to barriers of care and were less likely to believe that any help they might receive would be rendered confidentially (Reference Langston, Greenberg and FearLangston 2009). This may explain the finding by the charity Combat Stress that the average delay between symptom onset and presentation to services is 13 years for veterans (Combat Stress, personal communication 2007). One attempt to address stigma while people are still serving has been the introduction of a peer-led stress management system which is embedded in the chain of command and does not rely on individuals seeking help from mental health professionals (Reference Gould, Greenberg and HethertonGould 2007). It is hoped that over time such programmes might result in a cultural shift within the organisation, de-stigmatising help-seeking and treatment of mental health problems in the still-serving military, which will in turn make help-seeking more likely once people leave military service.

MCQs

1. 1 The most common mental health problem in veterans is:

   1. a panic disorder

   2. b depressive disorder

   3. c personality disorder

   4. d post-traumatic stress disorder

   5. e drug dependence.

2. 2 Which of the following statements is not true about reservists:

   1. a the majority of reservists serve in support roles while deployed

   2. b reservists are more likely than regular soldiers to have mental health problems after returning from combat

   3. c reservists perceive that they are more at risk of injury and harm during deployment

   4. d reservists perceive that they have more trouble at home during deployment

   5. e reservists represent about an eighth of the strength of the British army.

3. 3 Among military personnel, mental health problems are more common in:

   1. a women

   2. b officer ranks

   3. c those who are married

   4. d those from an ethnic minority group

   5. e those who are older.

4. 4 As regards the services available to veterans and reservists in the UK:

   1. a there is no special service to assess the mental health of reservists in the UK

   2. b veterans with mental health problems are not entitled to a specialist assessment by Ministry of Defence clinicians

   3. c stigma is major barrier to help-seeking in veterans

   4. d cognitive–behavioural therapy is unlikely to help with post-traumatic stress disorder

   5. e most veterans have complex needs that cannot be met by the NHS.

5. 5 As regards combat veterans:

   1. a those with mental health problems are more likely to stay in the military

   2. b rates of unemployment in those who leave are about 25%

   3. c data from the Second World War suggest that many veterans benefited in terms of jobs and education as a result of their military service

   4. d those who served in the 1991 Gulf War were more likely to be unemployed than those who were in the military but did not deploy

   5. e evidence suggests that veterans' symptoms get worse after they leave the military.

MCQ answers

1		2		3		4		5
a	f	a	f	a	t	a	f	a	f
b	t	b	f	b	f	b	f	b	f
c	f	c	f	c	f	c	t	c	t
d	f	d	f	d	f	d	f	d	f
e	f	e	t	e	f	e	f	e	f