Department of Community Mental Health, Duchess of Kent's Barracks, Catterick Barracks, Catterick Garrison
Royal DPNS, Royal Hospital Haslar, Gosport
Herdmanflat Hospital, Haddington
Department of Community Mental Health, Duchess of Kent's Barracks, Catterick Garrison
Department of Community Mental Health, Venning Barracks, Donnington
Bristol Priory Hospital, Stapleton, Bristol, UK
Correspondence: Dr Mark Turner, c/o Department of Community Mental Health, Duchess of Kent's Barracks, Catterick Garrison, North Yorkshire DL9 4DF, UK. Tel/fax: +44 (0) 1748 829644; e-mail: mturner20{at}compuserve.com
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ABSTRACT |
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Aims To delineate the reasons for psychiatric aeromedical evacuation from Iraq from the start of build-up of UK forces in January 2003 until the end of October that year, 6 months after the end of formal hostilities.
Method A retrospective study was conducted of field and in-patient psychiatric assessments of 116 military personnel evacuated to the UK military psychiatric in-patient facility in Catterick Garrison.
Results Evacuees were mainly non-combatants (69%). A significant proportion were in reserve service (21%) and had a history of contact with mental health services (37%). Only 3% had a combat stress reaction. In over 85% of cases evacuation was for low mood attributed to separation from friends or family, or difficulties adjusting to the environment.
Conclusions These findings have implications especially for screening for suitability for deployment, and for understanding any longer-term mental health problems arising in veterans from Iraq.
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INTRODUCTION |
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METHOD |
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Data were not collected on the population presenting with psychiatric symptoms in the theatre of war who were not evacuated, or on those who were evacuated but discharged at the UK airhead. Statistical analysis was conducted using Pearson's chi-squared test for significant differences (P<0.05) between categorically grouped independent samples.
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RESULTS |
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Figure 1 shows the rates of
evacuation every 2 weeks from the time of the first psychiatric evacuation on
16 January 2003 until 30 October 2003, 6 months after formal hostilities
ended. The numbers of people in the sample evacuated during the pre-war, war
and post-war phases of the military operation were 30 (26%), 51 (44%) and 36
(31%) respectively. Table 1
shows the findings relating to the war role of those evacuated, their
psychiatric symptoms, their reasons for distress and evacuation and the ICD-10
disorder (World Health Organization,
1992) diagnosed in the UK. There were 32 combatants from infantry
or tank regiments, only 13 of whom (11% of the sample) presented to a
community psychiatric nurse in the field. The remaining 19, along with 58
others (two-thirds of the sample) presented to a field hospital. Nine (8%)
Naval personnel presented at sea. There was a significant difference
(P<0.05) between the distribution of causes of evacuation between
the three phases of the conflict, with an increased rate of environmental and
combat causes and a decreased rate of interpersonal causes during the war
phase (2=16.51, d.f.=8, P=0.04).
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DISCUSSION |
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Combat stress and nostalgia
It is easy to assume, as some elements of the media appear to have done in
relation to Iraq (Kite & Rayment,
2004), that all military psychiatric casualties arising during a
conflict will be suffering from acute stress reaction caused by the trauma of
battle, otherwise known as combat stress reaction. This, however, is not the
case. Combat troops fighting in the low-intensity conflicts that characterise
modern warfare, and support troops in any conflict, are not often exposed to
the kind of acute, overwhelming stress that is necessary for the symptoms of
combat stress reaction to develop. Instead, these groups typically present
with a range of less dramatic symptoms that are characteristic of adjustment
disorders and almost invariably including low mood. They are, incidentally,
not dissimilar to those seen in military personnel during peacetime
(Neal et al, 2003). As
with combat stress reaction, the symptoms in question are situational, but
since separation from family and friends - not combat - is the most
significant aetiological variable, the clinical picture has been described as
homesickness or nostalgia
(Jones, 1995). Other important
aetiological variables include difficulty coping with the physical
environment. Our findings that those evacuated were mainly from support units
and had difficulty coping with separation and the environment suggest that
most psychiatric casualties from Iraq were broadly of this
nostalgic type. However, what about our finding that the rate of
psychiatric casualties dramatically decreased after the war ended? This
appears to suggest that, contrary to what troops themselves reported, fear of
becoming a casualty was the primary cause of symptoms. This possibility is
supported by the fact that in recent large-scale military exercises abroad
there were relatively few psychiatric casualties, and also by our finding that
most psychiatric symptoms had resolved by the time of arrival in the UK. In
order to explain the inconsistency between presenting complaints and reduction
in evacuations after the war ended, we need to consider that support troops
may not be cognizant that fear is the ultimate cause of their symptoms, and
even when they are, they may find it difficult to admit to this when they are
not literally in the firing line. It is a fact that in modern conflict the
physical casualties are often not from the élite units doing most of
the fighting, because poorly equipped armies prefer soft
targets. Increasingly, therefore, it is deployment to a war zone itself, and
not just combat, that puts troops at risk.
Predisposition: battle, military unit and personal characteristics
In a sense, then, modern conflicts such as the war in Iraq seem to blur the
traditional distinctions between combat and support troops, and therefore
between combat stress reaction and nostalgia. In view of this, perhaps we
ought to accept a broader definition of combat stress reaction in order to
accommodate the way in which modern conflict exposes different types of troops
to similar stresses. We know a reasonable amount about the aetiology of this
disorder, and this approach may provide us with a means of modelling
vulnerability in military personnel that allows us to explain some of our
findings. We know, for example, that the incidence of combat stress reaction
increases with battle intensity as measured by the number of physical
casualties, but is modified by a range of factors related to the battle, the
military unit and the individual. More specifically, the incidence of combat
stress reaction increases if:
The incidence of this condition also increases if unit morale is poor (which it is in units that are not cohesive and lack confidence in their skills), if equipment and leadership are poor, and if the legitimacy of the conflict in which troops are fighting is in question (Belenky et al, 1987). Lastly, not all military personnel carry the same risk of developing combat stress reaction: Reserve service, older age, low educational level, low rank and low combat suitability are all associated with an increased risk (Solomon et al, 1987a). If we now apply these findings to military personnel in general we can predict that, whatever the context, troops from the least élite units, especially those who are older and in Reserve service, will be the first to present with psychiatric difficulties. This is entirely consistent with our findings in relation to Iraq.
Treatment, repatriation, vulnerability and suitability
Knowledge of the aetiology of combat stress reaction can therefore be
generalised to help us to understand the causes of the psychiatric evacuations
from Iraq. However, this is where the analogies between combat stress reaction
and nostalgia end. Whether or not the person has been exposed to formal combat
is fundamental to treatment and prognosis and to preventing the kind of
aetiological misattributions referred to in our introduction. Traditional
forward psychiatry treats combat stress reaction by returning
troops to combat in order to preclude the detrimental psychosocial
consequences of psychiatric evacuation
(Jones & Wessely, 2003).
Such consequences include a damaged military identity and long-term mental
health problems. However, when troops develop psychiatric difficulties under
what, by military standards, is not extreme stress, the question of retaining
them in theatre becomes more problematic. This is because, as our findings
suggest, longer-term mental health problems and a relatively poor military
identity are a cause and not a consequence of military personnel failing to
cope. To continue to expose such individuals to stresses that exacerbate their
immediate symptoms, without the prospect of a longer-term advantage, is not
only questionable from an ethical perspective, but it imposes an enormous and
unnecessary administrative burden on unit commanders. The majority of troops
who have psychiatric difficulties without being exposed to combat are simply
unsuitable for deployment, and once this is recognised it is entirely
appropriate that, as with the psychiatric casualties from Iraq, they are
repatriated. Indeed, in terms of screening out vulnerable troops in order to
reduce longer-term psychological morbidity in veterans, although there is no
instrument that can be used to predict which troops will develop combat stress
reaction (Jones et al,
2003), it may not be difficult to predict which troops will
develop non-combat-related psychiatric difficulties during deployment. Given
the aforementioned similarities between psychiatric presentations in combat
operation support troops and those in military personnel during peacetime,
generally speaking it will be those who have already suffered from a
psychiatric illness and/or those who show signs of being temperamentally
unsuited to all forms of military service
(Turner & Neal, 2004).
Veterans' mental health: neuroses and traumatic neuroses
As one would expect, combat stress reaction is a robust predictor of
post-conflict psychological morbidity in veterans. Solomon et al
(1987b), for example,
found that 59% of an Israeli cohort of Lebanon war veterans with this
condition developed post-traumatic stress disorder (PTSD). This, incidentally,
is notwithstanding the finding that in the study in question some 16% of
veterans without combat stress reaction developed PTSD and also that some
veterans with combat stress reaction fail to present until their problems have
become chronic. Similarly, one might also reasonably expect that
non-combat-related psychiatric presentation predicts long-term psychological
morbidity in veterans. However, if further research does show this to be the
case, it will almost certainly be for entirely different reasons, which stand
to be obscured if the aetiological importance of combat is ignored. Generally
speaking, military personnel who present with non-combat-related psychiatric
difficulties have not been traumatised. The individuals in question are
psychologically vulnerable and may be temperamentally unsuited to military
service, have a history of mental illness, or both. With these characteristics
it is predictable that a good proportion of them will go on to develop
longer-term mental health problems. Because these problems are likely to be
towards the minor mental illness/personality-related end of the spectrum, they
will be difficult to define. It is under these circumstances that
misattributions are more likely to take hold and that pre-existent neurotic
difficulties become misinterpreted as PTSD. The best way of preventing this
(and the associated detrimental consequences for veterans) is by refusing to
compromise over the distinction between veterans who have been traumatised and
those who have not.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication July 16, 2004. Revision received September 14, 2004. Accepted for publication September 30, 2004.