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Overall, mental disorders among UK military personnel stable between 2003 and 2009; but deployment to Iraq or Afghanistan increases troops' risk of alcohol misuse

13th May 2010

A major new study funded by the UK Ministry of Defence has shown that overall, the prevalence of mental health disorders (including anxiety and depression) among UK troops remained stable between 2003 and 2009-for example the rates of post traumatic stress disorder (PTSD) remained between 3 and 4%. 

Furthermore, multiple deployments to Iraq and Afghanistan appear to have no effect on prevalence of PTSD. However, UK military personnel deployed to Iraq or Afghanistan have a 22% higher risk of alcohol misuse than their fellow troops who have not been deployed. The findings are reported in an Article published Online First and in an upcoming Lancet, written by Dr Nicola Fear, Academic Centre for Defence Mental Health, King's College London, and Professor Simon Wessely, Institute of Psychiatry, King's College London, UK, and colleagues.

Concerns have been raised about the psychological effect of continued combat exposure and of repeated deployments. In this study, the authors examined the consequences of deployment to Iraq and Afghanistan on the mental health of UK armed forces from 2003 to 2009, the effect of multiple deployments, and time since return from deployment.

The authors re-assessed the prevalence of probable mental disorders in participants of their previous study (2003-05). In addition, they studied two new randomly chosen samples: those with recent deployment to Afghanistan, and those who had joined the UK armed forces since April, 2003, to ensure that the final sample continued to be representative of the UK armed forces as a whole. Between November, 2007 and September, 2009, participants completed a questionnaire about their deployment experiences and health.

A total 9990 (56%) participants completed the study questionnaire (8278 regulars, 1712 reservists). The prevalence of probable PTSD was 4% (376 affected), 20% for symptoms of common mental disorders, and 13% for alcohol misuse. Regulars who had been deployed to Iraq or Afghanistan were 22% more likely to misuse alcohol* than regulars who had not been deployed; and reservists who had been deployed to Iraq or Afghanistan were almost three times as likely to suffer probable PTSD than reservists not deployed. There was a low prevalence of PTSD among the non-deployed reservists (1.8%) and that the authors note the prevalence rate among deployed reservists is also low 5.0%. Regular personnel in combat roles were almost twice as likely as those in combat service support roles to report probable PTSD.

There was no association with number of deployments for any outcome. There was some evidence for a small increase in the reporting of probable PTSD with increasing length of time spent at home since returning from deployment, but this increase was not as great as some have predicted.

The authors say: "Symptoms of common mental disorders and alcohol misuse remain the most frequently reported mental disorders in UK armed forces personnel, whereas the prevalence of probable post-traumatic stress disorder was low. These findings show the importance of continued health surveillance of UK military personnel."

They add: "Our main finding is that, overall, the prevalence of mental disorders in the UK armed forces remained stable between 2003 and 2009... Findings from this study suggest that the mental health of the UK armed forces has not changed since our initial study. This finding, although reassuring, is also surprising because the war in Iraq turned out to be a prolonged deployment, and UK military personnel in southern Iraq began to be exposed to increased levels of combat. Further, there has been an escalation in the UK commitment to Afghanistan, with substantial numbers of UK military personnel being deployed to Helmand province, where fighting has been intense. Many UK military personnel have now had multiple deployments to either or both operational locations, yet we noted that multiple deployments were not associated with mental health disorders."

The authors note that concerns have been raised about the long-term effect of deployment on the mental health of the UK armed forces, particularly the expected so-called tidal wave of mental health problems. They say: "However, we report only a small increase in the reporting of probable post-traumatic stress disorder with time since return from deployment. Our present analysis showed an effect of deployment on the reporting of alcohol misuse, and alcohol misuse continues to be greatest in those holding combat roles."

They add: "Despite the fact that a number of our study participants have undertaken multiple deployments, we did not find an association between the number of deployments and probable mental disorders. This finding might be partly explained by selection or the so-called healthy warrior effect, in which those who were unwell as a result of previous deployment have less chance of subsequent deployment, whereas those who are more psychologically robust have an increased chance of deployment."

In terms of government policy, the authors say their finding of no association between multiple deployments and mental ill health can be viewed as support for the appropriateness of the UK military's harmony guidelines, which outline the recommended number of deployments and length of time between deployments for the UK armed forces. The authors suggest that the actual length of time deployed over 3 years might be more important than the number of deployments. The authors add: "A more rigorous analysis will be needed to explore the connection between number of deployments, cumulative length of time deployed, and mental disorders."

The authors say that most of the current initiatives to improve the mental health of the armed forces, in both the UK and USA, are related to PTSD. But they point out in the UK, at least, alcohol use is more of a problem, both before and after deployment. On the other hand, they continue to report an increase in mental health problems including PTSD in specific groups as a result of deployment-namely combat personnel and reservists.

The authors conclude: "The absolute number of military personnel requiring support or treatment is increasing. This rise is not because of an increase in the rate of mental disorders, but as more of the UK armed forces are deployed, the number of people needing help will inevitably increase. This finding should not be taken as evidence that the situation is getting worse, but it does mean that military mental health services, service charities, and the UK national health system should anticipate a steady increase in the number of serving and ex-service personnel needing support."

In an accompanying Comment, Professor Glyn Lewis, University of Bristol, UK, notes that alcohol is banned when troops are deployed, but alcohol is cheaper for regular troops when they are in bases overseas. He says: "Reducing the harmful use of alcohol is
a challenge for the general population but alcohol does seem to be a particular problem in military culture."

He concludes: "Keeping service personnel fit and healthy is important for them and for their ability to carry out their demanding roles. Psychiatric illness is common in all walks of life and those serving in the military are not immune. Indeed, there are aspects of military life that would increase the risk of some disorders, such as post-traumatic stress disorder. There is increasing realisation that the modern military must look after the minds as well as the bodies of serving and no-longer serving members of the armed forces. The UK Ministry of Defence has shown a commendable response to this issue. The UK has funded a major research programme at King's College London, developed a network of mental health units, and addressed health concerns in reservists. Preventing psychiatric illness is a major public health problem and it seems that the UK military are beginning
to take this challenge seriously."
A linked Lancet Editorial says that "contrary to reports in the mainstream media, there is not an epidemic of mental health problems in this group of service personnel".
Regarding alcohol, the Editorial says hazardous drinking continues to be a serious problem for the armed forces,saying : "This group is at increased risk of the social complications of excessive drinking such as violence and relationship breakdowns. Although having introduced some alcohol-control policies, the armed forces need to reassess whether these are rigorous enough." It adds that the higher prevlance of PTSD in reservists means they could require support to return to civilian life, from both the Minsitry of Defence and across government.
The Editorial concludes: "Reassuring as the key findings of this paper are, they should not lead to complacency about the future health status of this population. The next UK Government has an ethical duty to support the continued long-term follow-up of those who have served in Iraq and Afghanistan. The end of their active service in these countries should not signal the end of society's service to them."

For Dr Nicola Fear, Professor Simon Wessely and Professor Matthew Hotopf; please contact The Institute of Psychiatry, King's College London press office:  Louise Pratt, +44 (0) 207 5377/5378 / +44 (0) 7966 265084 E) louise.a.pratt@kcl.ac.uk

Or the Science Media Centre T) +44 (0) 20 7670 2981 E) ffox@ri.ac.uk

Professor Glyn Lewis, University of Bristol, UK. T) +44 (0) 774 318 3734 E) Glyn.Lewis@bristol.ac.uk

The Lancet Press Office T) +44 (0) 20 7424 4949 E) tony.kirby@lancet.com

Note to editors: *alcohol misuse is defined using the World Health Organisation's Alcohol Use Disorders Identification Test (AUDIT), this is a 10-item measure with scores ranging from 0 to 40.  We have defined alcohol misuse as those with a score of 16+ (defined as hazardous alcohol use which is harmful for health)

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