King's Centre for Military Health Research, Guy's, King's and St Thomas' School of Medicine, King's College London, UK
King's Centre for Military Health Research, Guy's, King's and St Thomas' School of Medicine, King's College London, UK
Correspondence: Dr Amy Iversen, Department of Psychological Medicine, Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK. Tel: +44 (0)20 7848 0796; fax: +44 (0)20 7848 0408; e-mail: A.Iversen{at}iop.kcl.ac.uk
Declaration of interest S.W. is Honorary Civilian Advisor in Psychiatry (unpaid) to the British Army Medical Services. Funding detailed in Acknowledgements.
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To describe the frequency and associations of common mental disorders and help-seeking behaviours in a representative sample of UK veterans at high risk of mental health problems.
Method A cross-sectional telephone survey of 496 vulnerable ex-service personnel selected from an existing epidemiological military cohort.
Results The response rate was 64%; 44% of these had a psychiatric diagnosis, most commonly depression. Those with a diagnosis were more likely to be of lower rank and divorced or separated. Just over half of those with self-reported mental health problems were currently seeking help, most from their general practitioners. Most help-seekers received treatment, usually medication; 28% were in touch with a service charity and 4% were receiving cognitive-behavioural therapy.
Conclusions Depression is more common than post-traumatic stress disorder in UK ex-service personnel. Only about half of those who have a diagnosis are seeking help currently, and few see specialists.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Our case group consisted of 701 individuals for whom we had already collected two waves of data, at baseline (1997) and at follow-up (2001). Inclusion criteria were scores of 3 or more on the 12-item General Health Questionnaire (GHQ; Goldberg & Williams, 1988) at stages 1 and 3 of our original investigation (n=636), and all those who were unemployed at stage 3, having left the services by stage 1 (n=107). Individuals fulfilling GHQ caseness at stages 1 and 3 were selected on the basis of an assumption of a degree of chronicity of mental health problems, as opposed to transient distress. As the unemployed individuals were still not working 4-5 years after leaving the armed forces, chronicity of employment difficulties was assumed. Inevitably, there was overlap between these two groups: 42 of 107 individuals who were unemployed also fulfilled GHQ criteria. Members of the sample who were still serving in the armed forces at the point of last follow-up (n=205) were excluded from this study, leaving a sample group of 496. The advantages of using the existing cohort were that participants were originally randomly selected, and were therefore not seeking treatment or compensation, and that vulnerable individuals could be selected from the cohort on the basis of their previous questionnaire responses.
Procedure
All potential participants who had given consent to follow-up at last
contact were contacted by letter at the start of the study. For all letters
returned to the unit undelivered, electoral register searches were used in
order to clarify a change of address. After a period of 4 weeks, telephone
interviews conducted by two research associates commenced. The research
associates were masked to any previous information collected about the
individuals contacted, other than that they fulfilled criteria to participate.
A list of non-responders who had agreed to take part when last contacted but
were untraceable was drawn up, and the Department for Work and Pensions sent
letters to these individuals on our behalf (using up-to-date addresses) asking
them to make contact to provide their new address details. Two members of the
cohort were in prison, and we managed to interview one of them using a
modified postal questionnaire.
Measures
The final questionnaire used a combination of existing measures and new
questions arising out of our interviews with veterans and veteran
organisations. Additional information included details of individuals (age,
marital status) as well as details of their military experience: length of
service, time elapsed since leaving, method of leaving, whether participants
had been given a diagnosis of post-traumatic stress disorder (PTSD) at any
time and who had made that diagnosis. We also explored participants
experiences of primary healthcare, what treatments they had received and what
role specialist services played.
A modified version of the Primary Care Evaluation of Mental Disorders (PRIME-MD; Spitzer et al, 1994) was administered to detect the presence or absense of psychiatric disorders, according to prearranged algorithms (excluding sections on eating disorders and somatoform disorders). In addition, a short screening scale designed to detect the presence of PTSD in individuals who self-reported exposure to trauma was administered (Breslau et al, 1999). The scale is based on the DSM-IV diagnostic criteria for PTSD (American Psychiatric Association, 1994) and consists of a seven-item structured telephone interview schedule.
Statistical methods
Data were analysed using the Statistical Package for the Social Sciences,
version 11.0. In order to undertake longitudinal analysis, several variables
from our stage 3 data (2001) were included in the final analysis. The majority
of results are presented as descriptive statistics with 95% confidence limits.
Pre-defined comparisons were made using either 2- or
t-tests where appropriate.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
Sample
The final study sample consisted of 315 individuals, all of whom had left
the military and 98% of whom had been full-time employees; 12% were women.
Their mean age was 40 years (s.d.=8.5). Almost half (49.5%) were of junior
rank on leaving, 38.7% were non-commissioned officers and 11.7% were officers;
78.6% had been in the Army, 11.8% in the Royal Air Force, 7.7% in the Royal
Navy/Marines and 1.9% in the Territorial Army. The average length of service
was 14.3 years (s.d.=8.1) and the average time since leaving the forces was
8.3 years (s.d.=5.6). The majority (62.9%) of the sample were married, 16.3%
were divorced or separated and 20.8% were single or cohabiting.
Diagnosis
On structured interview, 138/315 (43.8%) of the sample were found to have a
psychiatric diagnosis. Many individuals had two or more psychiatric diagnoses,
and there was a total of 313 diagnostic events. Of these, 53.4%
were depressive-spectrum disorders, 18.2% anxiety disorders, 16.3% PTSD and
11.8% probable alcohol dependence (Table
2). The most common depressive-spectrum disorder was major
depressive disorder and the most common anxiety disorder was anxiety disorder
not otherwise specified. Three-quarters of those who had PTSD (75.5%) also had
a comorbid diagnosis, compared with a third (33.1%) who did not
(2 30.7, d.f.=1, P
40.001; OR=6.2, 95% CI 3.1-13).
In 34.7% of PTSD cases the individual also had a diagnosis of probable alcohol
dependence, as opposed to 8.1% of those without PTSD (
2=26.6,
d.f.=1, P
40.001; OR=6.1, 95% CI 2.9-13). The majority of PTSD
diagnoses were made by military or civilian psychiatrists (30.0% and 26.7%,
respectively) rather than by primary care physicians (3.3%).
|
Risk factors for psychiatric diagnosis
Most participants recognised that they had difficulties; 81.2% of those
with a psychiatric diagnosis reported that they had a mental health problem,
compared with 20.9% of those without (Table
3). Those with a current diagnosis had higher previous GHQ scores
than those without, confirming a degree of chronicity of difficulties. Those
with a psychiatric diagnosis were significantly more likely to be of lower
rank and divorced or separated. Gender, service arm and deployment group did
not predict having a diagnosis.
|
In service
Almost one-third of the sample (28.9%; 90/311) self-reported that they had
a mental problem while in service. People who reported problems in service
were more likely to report current mental health problems
(2=16.2, d.f.=1, P
40.001; OR=2.8, 95% CI 1.7-4.6)
and more likely to have a current diagnosis (
2=17.6, d.f.=1,
P
0.001; OR=2.9, 95% CI 1.8-4.9). The most common problems
reported in service were depression (48.3%) and stress (37.9%).
Half of those who had problems in service reported that they had sought help.
The most common reason for not seeking help was the embarrassment or
stigma of consulting. Of those who did consult, 69.6% reported
receiving help from their medical officer (military primary care) and 56.5%
went on to see a psychiatrist.
Current help-seeking
Of those who self-reported mental health problems, 58.4% were currently
seeking help. Those who sought help were no more likely to have a diagnosis on
the PRIME-MD than who did not; however, those who were help-seeking tended to
have higher previous GHQ scores (measured 1 year previously) than those who
were not (Table 4). Those who
were currently unemployed were more likely to seek help than those who were
not. Gender, age, marital status, rank and service arm did not appear to
influence help-seeking behaviour. Only 28.2% of the sample had sought advice
from a service charity. Those who contacted a service charity had higher mean
GHQ score than those who did not (8.4 v. 6.8, P=0.01).
|
Most veterans sought help from their general practitioners (86.9%), with a minority seeing a psychiatrist (28.7%) or a psychologist (8.1%). Those who were seeing a psychiatrist had slightly higher mean scores on their previous GHQ assessment than those who were not (mean 9.3 v. 8.6), but this difference did not reach significance. Only 6.6% had received input from a community psychiatric nurse during their period of mental ill health.
Among those who reported problems who were not help-seeking (n=79), the most common reasons for not seeking help were I could deal with it myself (72%) and the perceived stigma and embarrassment of consulting (20%).
Treatment
Of the help-seekers, 101/122 (83%) received some form of treatment. In 72%
of cases this was overseen by primary care, with only 9% being organised by a
psychiatrist. Those with alcohol dependence (70% in treatment) and PTSD (73%
in treatment) were less likely to be treated than those with depression (76%
in treatment). Of the treated sample, 70% reported receiving medication, 48%
received non-directive counselling, 9% received psychotherapy and 4% received
cognitive-behavioural therapy.
Employment
With regard to employment status 14.0% (42/299) of the sample described
themselves as unemployed currently. Of those participants who were unemployed
at stage 3 of the original study, 36.4% had become employed in the past year.
The great majority (95.9%) who were employed at the point of last contact
remained in full-time employment. People who were unemployed were no more
likely to have a diagnosis than those who were not. Although the unemployed
had slightly higher GHQ scores on average than those who were working (7.8
v. 7.0), this difference was not significant. Those with a current
diagnosis had experienced longer periods of unemployment and had greater job
transiency than those without a current diagnosis.
Discussion
The important findings from this study are twofold. First, it confirms that
the most important diagnoses in ex-service personnel are classic psychiatric
disorders rather than specific service-related psychiatric injury. Second,
only approximately half of those who have a diagnosis are seeking help
currently, and few of those who have consulted are receiving specialist
help.
Diagnoses
The most common disorders were depressive episodes and anxiety syndromes.
Data from the USA confirm that the most common psychiatric disorders in
help-seeking veterans are alcohol and substance-related disorders, adjustment
disorders, mood disorders (mostly major depressive disorder) and personality
disorders, with only 5.6% of participants in a recent out-patient survey
fulfilling criteria for PTSD (Hoge et
al, 2002).
In our study, participants with PTSD almost invariably had a comorbid diagnosis, a similar finding to previous studies (Helzer et al, 1987). Despite the fact that most people who receive a diagnosis of PTSD initially present to primary care settings (Dickinson et al, 1998), in our sample this diagnosis was almost exclusively made by psychiatrists. Even then, only about half of those found to have PTSD on structured interview had been given this diagnosis by any doctor, despite the occupational risk of PTSD in this group.
Vulnerability factors
The most vulnerable people in this cohort were single, came from the lower
ranks and appeared to be more likely to have served in the Army. Data released
by the Defence Analytical Services Agency on suicide in the military confirms
that although the majority of military personnel have lower rates of suicide
than civilians, young, male Army recruits have higher rates than their
civilian counterparts (Fear,
2003). Work among Norwegian peace-keepers has highlighted
being single as an important post-military risk factor for
completed suicide (Thorsen et al,
2003). This selective vulnerability appears to be mirrored in the
veteran population.
Help-seeking
The reluctance among study participants to seek help is striking,
especially in terms of self-report of help-seeking during service. Only half
of those who reported problems while in service admitted to seeking help, with
this proportion only increasing slightly when individuals encountered problems
as veterans. This is comparable with civilian rates of consulting with common
mental disorders of 39-50% (Meltzer et
al, 2003). As with the civilian literature
(Meltzer et al,
2003), the most common reason for veterans not seeking help was a
sense of resilience and stoicism: It's a problem I should be able to
deal with myself. The nature of military culture, with its emphasis on
resilience, courage and masculine stereotypes almost certainly amplifies this
reticence. Those who reported problems in service also reported the
embarrassment and stigma of admitting a need for help. However, for those who
reported seeking help while still in service, access to a psychiatrist was
more likely (56.5% v. 28.7% in veterans), perhaps because access to
all medical services is easier for serving personnel.
Unemployment and help-seeking
The finding that unemployment predicts help-seeking is an interesting one,
which has been reported previously
(Verhaak, 1993;
Bebbington et al,
2000b). It may be that those in employment are more
reticent about being labelled as having mental health problems than the
unemployed, or that those who are unemployed have more severe problems and
hence are more motivated to seek help, although our study was not able to
demonstrate this conclusively. Finally, full-time employment may lead to
reduced time for consulting and neglect of health needs.
Treatment
Most who sought help used primary care, and only a minority had contact
with specialist services. The majority of those who were unwell were receiving
treatment from their general practitioner in the form of (antidepressant)
medication. Only a minority saw a psychiatrist or other mental health
professional, and the advice and support that the veteran charities provide
was not often accessed. Despite good evidence of benefit for psychological
treatments for depression and PTSD, only a minority of participants who sought
help were receiving these interventions, and only 4% had been offered the best
evidence-based treatment, cognitive-behavioural therapy. There was a sense
that even those who had seen a psychiatrist were not engaged with ongoing
service provision; few of those with one or more diagnoses had community
psychiatric nurse input. Once again, veterans' experiences appear to mirror
those of the general civilian population with common mental disorders
(Bebbington et al,
2000a,b);
Andrews et al,
2001).
Implications
There are two major policy implications for this work. First, ex-service
personnel are reluctant to seek help, both while in service and after leaving.
The military therefore should continue to encourage a culture in which
consulting about symptoms is acceptable - a cultural shift that will benefit
individuals even after they have left the armed forces. This needs to be
balanced against the need to reinforce personal resilience, an essential
quality for members of the armed forces. Second, it is now well established
that untreated mental health problems are associated with profound functional
and social disability and suffering for the individual, as well as increased
use of medical services, and higher costs borne by individuals and healthcare
institutions alike. Therefore those who do consult should have access to
high-quality, effective treatments delivered as swiftly as possible. Some
countries, most notably the USA and Australia, have established separate
healthcare systems dealing with veterans after they leave the armed forces. In
the UK our universal access to healthcare means we do not have such a system.
It is a question of policy as to whether military service, with all its
attendant risks, entitles veterans to better access to specialist services
than those who have not served in the military. At present, however, we are
not meeting the treatment needs of this group.
Limitations of this study
As with any follow-up study, the response rate is of paramount importance.
The most disappointing response rates seen in longitudinal studies are in
young, single, male, urban cohorts (Eaker
et al, 1998), and this is an accurate description of the
recent ex-military population in the UK. In addition, the sample was selected
on the basis of chronic mental health problems and/or social exclusion, which
adds to the difficulties of following individuals up.
Our analysis of non-responders for this study showed that there were minimal differences between those who were sampled and those who were lost to follow-up, therefore we would anticipate that the response rate of 64% introduced only limited bias. The small differences observed all point to non-responders being slightly more unwell and symptomatic than responders, suggesting that the true situation, if anything, might be slightly worse than we report. In addition, it should be pointed out that the sample group itself (non-responders included) is not a random selection of vulnerable veterans. A certain degree of compliance has been necessary for participants to make it this far; they had all opted to take part in both stage 1 and stage 2 of our original study, which achieved response rates of 70% and 75% respectively after vigorous tracing (Hotopf et al, 2003). It is likely, therefore, that this sample is less socially excluded and less unwell than a random sample of veterans might be. It is certainly true that the severely socially excluded minority (e.g. the homeless) of this cohort have been missed at each stage of the study.
By necessity, any study that relies on retrospective report is vulnerable to recall bias. In addition, the measures of previous mental health problems and of current help-seeking and treatment were based on self-report; a more accurate method would have sought objective corroboration of individual's treatment history using medical record verification. However, previous studies have shown that self-report of service use has acceptable accuracy (Golding et al, 1988).
Finally, this study draws on a cohort of those who were serving in the armed forces at one point in time, in 1991. It therefore captures a snapshot of the military at that time. The research findings may not be applicable to earlier or later military cohorts.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Andrews, G., Henderson, S. & Hall, W.
(2001) Prevalence, comorbidity, disability and service
utilisation: overview of the Australian National Mental Health Survey.
British Journal of Psychiatry,
178, 145
-153.
Bebbington, P. E., Brugha, T. S., Meltzer, H., et al (2000a) Neurotic disorders and the receipt of psychiatric treatment. Psychological Medicine, 30, 1369 -1376.[CrossRef][Medline]
Bebbington, P. E., Meltzer, H., Brugha, T. S., et al (2000b) Unequal access and unmet need: neurotic disorders and the use of primary care services. Psychological Medicine, 30, 1359 -1367.[CrossRef][Medline]
Breslau, N., Peterson, E. L., Kessler, R. C., et al
(1999) Short screening scale for DSM-IV posttraumatic stress
disorder. American Journal of Psychiatry,
156, 908
-911.
Card, J. (1987) Epidemiology of PTSD in a national cohort of Vietnam veterans. Journal of Clinical Psychology, 43, 6 -17.[Medline]
Dickinson, L. M., deGruy, F. V., Dickinson, W. P., et al (1998) Complex posttraumatic stress disorder: evidence from the primary care setting. General Hospital Psychiatry, 20, 214 -224.[CrossRef][Medline]
Eaker, S., Bergstron, R., Bergstrom, A., et al (1998) Response rate to mailed epidemiologic questionnaires: a population-based randomized trial of variations in design and mailing routines. American Journal of Epidemiology, 147, 74-82.[Abstract]
Fear, N. (2003) Suicide and Open Verdict Deaths among Males in the UK Civilian Population and the UK Military. London: Defence Analytic Services Agency.
Goldberg, D. & Williams, P. (1988) A Users' Guide to the General Health Questionnaire. Windsor: NFER-Nelson.
Golding, J. M., Gongla, P. & Brownell, A. (1988) Feasibility of validating survey self-reports of mental health service use. American Journal of Community Psychology, 16, 39 -51.[CrossRef][Medline]
Helzer, J., Robins, L. & McEvoy, L. (1987) Posttraumatic stress disorder in the general population: findings of the epidemiologic catchment area survey. New England Journal of Medicine, 317, 1630 -1634.[Abstract]
Hoge, C., Lesikar, S. E., Guevara, R., et al (2002) Mental disorders among US military personnel in the 1990s: association with high levels of health care utilization and early military attrition. Amercian Journal of Psychiatry, 159, 1576 -1583.[CrossRef]
Hotopf, M., David, A. S., Hull, L., et al
(2003) Gulf War Illness - better, worse, or just the same?
BMJ, 327, 1370
-1372.
Ismail, K., Kent, K., Brugha, T., et al
(2002) The mental health of UK Gulf war veterans: phase 2 of
a two phase cohort study. BMJ,
325, 576.
Iversen, A., Nikolaou, V., Greenberg, N., et al (2005) What happens to British veterans when they leave the armed forces? European Journal of Public Health, in press.
Kulka, R., Schlenger, W., Fairbank, J., et al (1990) Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. New York: Brunner Mazel.
Meltzer, H., Bebbington, P., Brugha, T., et al (2003) The reluctance to seek treatment for neurotic disorders. International Review of Psychiatry, 15, 123 -128.[CrossRef][Medline]
O'Brien, L. S. & Hughes, S. J. (1991) Symptoms of post-traumatic stress disorder in Falklands veterans five years after the conflict. British Journal of Psychiatry, 159, 135 -141.[Abstract]
Orner, R., Lynch, T. & Seed, P., (1993) Long-term traumatic stress reactions in British Falklands War veterans. British Journal of Clinical Psychology, 32, 457 -459.[Medline]
Spitzer, R. L., Williams, J. B., Kroenke, K., et al (1994) Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA, 272, 1749 -1756.[Abstract]
Thorsen, S., Mehlum, L. & Moeller, B. (2003) Suicide in peace-keepers: a cohort study of mortality from suicide in 22,275 Norwegian veterans from international peace-keeping operations. Social Psychiatry and Psychiatric Epidemiology, 38, 605 -610.[CrossRef][Medline]
Unwin, C., Blatchley, N., Coker, W., et al (1999) The health of United Kingdom servicemen who served in the Persian Gulf War. Lancet, 353, 169 -178.[CrossRef][Medline]
Verhaak, P. F. (1993) Analysis of referrals of mental health problems by general practitioners. British Journal of General Practice, 43, 203 -208.[Medline]
Wessely, S., Dandeker, C., Iversen, A., et al (2003) Improving Cross-departmental Support and Service Delivery for UK Veterans. London: Ministry of Defence, http://www.mod.uk/linked_files/publications/other/kings_college_report_jul_03.pdf
Received for publication July 13, 2004. Revision received October 27, 2004. Accepted for publication October 30, 2004.