Scoping Review: A Needs Based Assessment and Epidemiological Community-Based Survey of Ex-Service Personnel and their Families in Scotland

SECTION 5: Review of the Eminence- and Evidence-based Literature

5.1 Preface

The purpose of this section is to present a critical and selective review of the data which derived from the three sources of: (i) MoD and Government commissioned reviews; (ii) surveys commissioned by charities and agencies affiliated to the provision of the Veterans Initiative, and (iii) academic-based research reported in the peer review literature. In line with the terms of reference for the scoping study, this review reflects a UK focus with specific reference to data that would inform the national commitment to meeting the health and wellbeing needs of ex-Service personnel and their families in Scotland.

5.2 MoD AND GOVERNMENT COMMISSIONED REVIEWS

A summary of the documents identified is provided in Table 7. Analysis of the data obtained from this source was dedicated principally to identifying: (i) existing gaps in the implementation of the Veterans Initiative at the policy, health systems, provider practice and community behaviour levels, which may compromise its effectiveness in fulfilling its strategic outcomes, and (ii) outcomes and gaps in the emergent eminence- and evidence-base.

Table 7. Summary of MoD and Government Commissioned Reviews

Year	Title and Source
Delivery of Cross Departmental Support and Services for Veterans
2003	"Improving the Delivery of Cross Departmental Support and Services for Veterans" (Dandeker et al, MOD)
Defence Healthcare (In-Service & Post-Service)
2006	"Review of Healthcare" (Defence Committee)
2008	"Review of the Defence Medical Services" (Healthcare Commission)
2010	"Treating Injury and Illness Arising on Military Operations" (National Audit Office)
Transition
2007	"Leaving the Services" (National Audit Office)
Homelessness
2005	"Homelessness Feasibility Study" (Dandeker et al, MOD)
Health and Social Outcomes/ Health Service Experiences
2009	"Health and Social Outcomes and Health Service Experiences of UK Military Veterans. A Summary of the Evidence" (Fear et al, Department of Health)
Community Mental Health
2010	"An Evaluation of Six Community Mental Health Pilots for Veterans of the Armed Forces" (Dent-Brown et al, MOD)

5.2.1 Delivery of Cross Departmental Support and Services for Veterans

Dandeker et al (2003)

• Between July 2002 and March 2003, a multidisciplinary^[143] team of researchers from King's College London (KCL) conducted the first scoping review in the UK to:
  • address the "neglected problem" of how best to identify the needs of "vulnerable" Veterans, and
  • identify ways to improve the delivery of cross-departmental support and services to Veterans.
• The four aims of this seminal review were to:
  • formulate a Veterans-related "needs" map in respect of those who encounter problems with social exclusion;
  • match this map against what was the current provision of services;
  • identify where the gaps are in the delivery of services, and
  • delineate a research strategy which would be commensurate with the views of key stakeholders.
• In fulfilment of these aims, its objectives were to:
  • understand the main ways in which Veterans may be at risk of social exclusion;
  • understand how military life may contribute to social exclusion;
  • propose future research directions and priorities, and
  • identify ways in which the Government might effect a difference in respect of Veteran-related service delivery.
• By means of a multimodal approach, which combined qualitative and quantitative methodologies, data were obtained from the following sources.
  • A systematic review of the UK literature: This was combined with a "narrative" overview of the world literature to ensure a comprehensive coverage.
  • Stakeholder interviews: Representatives from 14 Veterans' organisations were interviewed using a standardised interview schedule.
  • In-depth qualitative interviews: Face-to-face interviews with 52 vulnerable Veterans using a structured interview schedule.
  • Quantitative data analysis: The quantitative data were obtained from their existing KCL military cohort to conduct a cross-sectional and longitudinal analysis of Service leavers with the primary focus on economic outcomes. This included a telephone interview of 400 "at risk" Veterans^[144].
• Key themes to emerge from the systematic review of the UK literature were as follows.
  • Exposure to war and combat is a life-changing experience for those who serve.
  • Military life for most however is considered a positive experience, particularly for those younger recruits who may have come from disadvantaged backgrounds. As such, a military career enables these individuals to embark on a more "favourable life trajectory" than might otherwise have been the case.
  • The vast majority of ex-Service personnel do not therefore experience mental health problems whilst either in Service or after leaving Service.
  • The minority who do encounter problems "fare badly" and are at an increased risk of social exclusion. Pre-Service factors are considered to play a key role in this regard by exacerbating the development of post-discharge health and welfare problems in "vulnerable" Veterans.
  • The socio-economic context of military conflict is also a major determinant of the health and economic outcomes for Service leavers.
  • Deployment on operations has a deleterious impact on family and marital relationships.
• Key themes to emerge from the stakeholder interviews pertained to the following.
  • Problems with resettlement can be exacerbated by the "dependency culture" of the UK Armed Forces.
  • Another major problem related to military culture is the heavy ("culturally condoned") use of alcohol by Service personnel.
  • Media and public attention is dominated by a small number of high profile Veterans.
  • A deterioration in the understanding of the military by civic society due to has an adverse impact on Veterans who have to engage with the Local Authorities and Social Services.
  • By virtue of the "consumerist and individualistic" nature of contemporary society, younger Veterans are more likely to demand welfare assistance than older Veterans.
• The common themes to derive from the in-depth qualitative Veteran interviews highlighted the need to consider the following factors.
  • The blanket use of the term "Veteran" to describe those who leave Service.
  • The accessibility of the FTP.
  • Provision of training in life skills during Service and mentoring post-Service.
  • Differences between younger and older Veterans.
  • Vulnerabilities associated with medical discharge.
  • The "Catch-22" that exists in respect of unemployment and housing provision for Veterans.
• In focusing on economic outcomes, the key findings in respect of the quantitative analysis of data from the existing KCL military cohort showed that:
  • in excess of 75% of Service leavers effected a successful transition and gained employment after leaving (although no information was provided as to the stability of this employment);
  • deployment on operations did not adversely affect the likelihood of securing employment post-discharge so long as individuals did not suffer from physical or mental ill health, and
  • a key predictor of employment was impoverished mental health.
• In focusing on treatment needs and experiences as well as factors that influence help-seeking behaviour, the key interim findings from the telephone follow-up survey of "at risk" Veterans showed that:
  • a significant number (50%) did not seek help for mental health problems, the most common reason for which was a sense of self-reliance;
  • of those who were in contact with clinical services, all were being managed in primary care;
  • pharmacological treatment (particularly antidepressants) was most commonly used. Few had received specialist advice or treatment, and even fewer had received psychological therapies such as CBT, and
  • poor mental health was a key predictor in respect of the few who engaged with a Service charity.
• In undertaking this work, the KCL team have been instrumental in the UK by informing Veteran-related policy and strategy (as demonstrated in Section 2) and to scoping the nature and extent of the challenges associated with meeting the health and wellbeing needs of the "vulnerable" Veteran population. By focussing on this subgroup who are most "at risk" of social exclusion (i.e., those who encounter problems with homelessness, unemployment, substance misuse, physical and mental health problems), the outcome of that signal scoping review has highlighted the importance of considering the following factors.
  • The relationship between military service and the subsequent development of psychopathology (combat-related or otherwise) and problems of psychosocial adjustment post-service is highly complex due to the interplay of a number of vulnerability factors, viz, pre-Service, in-Service, transition, and post-Service.
  • Whilst military life for many Service personnel is a great "leveller", with many perceived positive benefits, there are aspects of military culture and ethos that may impede those who do encounter mental health problems from seeking timely and appropriate help. In addition, whilst the heavy consumption of alcohol is endorsed as an accepted part of military culture, this can cause serious problems for some Service personnel following discharge.
  • There are considerable challenges in tracking those who experience social exclusion as evidenced by the response rate of 50% for the telephone follow-up survey of "at risk" Veterans. To address this problem, Dandeker et al (2003) advocate the use of "aggressive tracing" of non-responders in order to avoid selection bias. The challenges associated with the tracking of the Veteran population will be addressed in Section 6.

5.2.2 Defence Healthcare (In-Service and Post-Service)

Defence Committee Review of Healthcare (2006)

• In October 2006, the Defence Committee undertook a wide-ranging inquiry into the provision of healthcare for the UK Armed Forces. It focussed on the following six key areas.

(i) Treatment process and procedures involved in the care of seriously injured Service personnel from point of wounding through to treatment received following evacuation from theatre.
(ii) Provision of rehabilitation for those with severe musculo-skeletal or neurological injuries.
(iii) Delivery of healthcare in respect of the relationship between the MoD and the NHS.
(iv) Healthcare provision for Service families and Veterans.
(v) Mental healthcare provision for Service personnel and for Veterans
(vi) Role of the Reserve personnel in the DMS.

• The inquiry comprised a series of visits in the UK (including to DMRC [Headley Court] and to Tyrwhitt House [Combat Stress]) and to overseas sites (including the deployed field hospital in the Contingency Operating Base [COB, Basra Air Station] and the Princess Mary Hospital [TPRM, RAF Akrotiri]). A visit was also made to the Regional Rehabilitation Unit (RRU) and the Medical Reception Station (MRS) at Redford Barracks in Edinburgh. Of the four evidence sessions conducted during the course of the inquiry, one took place in Edinburgh on 11 October 2007 involving the Royal College of Psychiatrists, the St John and Red Cross Defence Medical Welfare Service and officials from the then Scottish Executive.
• On the basis of the evidence obtained from the sources above, the Defence Committee commended the:
  • provision of "world class" clinical care for seriously injured Service personnel by the DMS working alongside the NHS;
  • provision of "exceptional" rehabilitation services, particularly by the DMRC [Headley Court];
  • concept of an integrated approach to service provision by the MoD, the NHS, charities, and welfare organisations (particularly in respect of capitalising on a "…proud tradition in the UK of linking the community with Service personnel who have been injured fighting on their behalf" p.3);
  • soundness of the MoD's decision to base secondary care around units embedded in NHS Trusts by virtue of the opportunities this arrangement provides for training and maintenance of skills whilst permitting the treatment of Service personnel in a quasi military environment;
  • Government's extension of the priority access to healthcare available to Veterans;
  • DMS for progress made in respect of mental healthcare provision, particularly in adopting a preventative approach such as the intended community-based model that incorporates NHS best practice, and
  • contribution of Combat Stress in helping to meet the needs of Veterans with mental health problems.
• In addition, the Defence Committee identified a number of key areas for improvement, which led to the following recommendations.
  • Government and voluntary organisations to be involved in the wider public debate about which services should be provided by each sector.
  • The DMS and the NHS to work together to enhance their sharing of best practice.
  • An MoD review of how it engages with other departments and administrations.
  • The Scottish Executive to examine its procedures for engagement and co-operation (given that the Defence Committee found the co-operation in Scotland to be "inadequate") and to examine how improvements could be effected.
  • The implementation of procedures which would facilitate the identification of Veterans in respect of priority access as opposed to the MoD relying on individuals to identify themselves as Veterans.
  • A more effective means of transferring medical records from military to civilian clinicians (e.g., an automatic system of transferring medical records and tracking Veterans in the NHS that incorporates an "opt out" option to provide a robust means of protecting privacy).
  • Financial investment in high-quality healthcare by the MoD to complement that of the NHS.
  • The systematic and robust identification and treatment of Veterans by Combat Stress.
  • A robust method of tracking Veterans and a comprehensive understanding of their problems by the NHS.
  • Public recognition of the contribution by the Reserve forces to the military and civic society.
  • The MoD to ensure that the Reserve forces are not subject to overstretch whilst maintaining adequate levels of recruitment and retention.

Healthcare Commission Review of the Defence Medical Services (2008)

• In January 2008, the Surgeon General (MoD) requested the Healthcare Commission to undertake an independent review of the quality of healthcare services provided by the DMS in the UK and overseas. This was the first time that the Healthcare Commission had received such a request from the MoD in view of the fact that the services provided by the DMS were outwith the scope of the Health and Social Care Act (2003); the legal framework within which the Healthcare Commission operates. The legislation required to bring the DMS within the regulatory remit was laid before Parliament in June 2008.
• Based on Standards for Better Health^[145], the overarching aim of that unique review was to promote the improvement in provision of service by the DMS by identifying good practice and areas in need of improvement. Moreover, it sought to assist the DMS to implement more "…robust governance of the quality of the care and treatment it provides." (March 2009, Commission for Healthcare Audit and Inspection, MOD, p.4). The outcome of that extensive review revealed both areas of "…exceptional good practice and expertise" (e.g., trauma management in theatre, medical emergency response and rehabilitation services) as well as "…several areas where improvement is needed" (e.g., the need for a clear governance structure and system for the entirety of the DMS).
• A total of 485 commentaries about the healthcare services provided by the DMS were summarised according to four main headings: (i) "the standards of care across the DMS"; (ii) "views of those who used the service"; (iii) "areas of exemplary practice", and (iv) "areas of good practice in clinical governance". Whilst 213 of the 300 comments received pertained to Primary Care, only 10 were received in relation to community health services. In terms of the number of respondents by role, the majority comprised members of the UK Armed forces (n=215), with 52 family dependants, 20 entitled civilians and 13 professional bodies. The review was advertised through the MoD internal communication systems, and a number of options were made available for respondents to submit their comments (e.g., completing an on-line feedback form or telephoning the Healthcare Commission). What is not clear however is how this sample was selected. For this reason, it is difficult to establish to what extent the views received are generalisable, particularly when only seven respondents expressed an opinion on the community mental health services (the majority of which were positive).
• However, whilst bearing this limitation in mind, it is interesting to note the concern raised by respondents (number unknown) about the closure of military hospitals in favour of NHS and independent acute healthcare providers. The preference from that review was for dedicated military hospitals to provide treatment and care for Service personnel rather than through contracted medical services provided by the NHS; a view shared by the 113,961 individuals who signed a petition to this effect which was delivered to Downing Street in August 2008.
• In stark contrast, the Defence Committee inquiry (see above) endorsed the wisdom of the MoD's decision to base its secondary care around units embedded in the NHS Trusts. A decision which derived from a spending review and which was substantiated by evidence derived from a study conducted by Dr David Rosser (UHB Medical Director) entitled "Military Hospitals for the Care of Military Battle Casualties". According to that study, the average number of 36 military patients receiving treatment at UHB at any one time during 2007 to 2008 was too small a number to enable surgeons to maintain effectively their skills. In examining the treatment provided to at least one military patient between 2005 and the first half of 2008 according to area of specialism (e.g., renal, knee and plastic surgery), UHB surgeons performed an average of 72 operations a year on NHS patients compared to four operations for military cases. The same situation was apparent in respect of hand surgery (253 civilians vs 7 military), and cardiothoracic surgery (549 civilians vs 3 military). Thus, whilst the figures clearly support the treatment of military personnel in the NHS, the views of those being treated does not necessarily correspond accordingly thereby enforcing the need to ensure that patient needs are taken into consideration in the planning and developing of services. The challenge therefore is to determine how best to meet those needs in a clinical and cost effective manner. According to the Healthcare Commission review, "… patients achieve healthcare benefits that meet their individual needs through healthcare decisions and services based on what assessed research evidence has shown provides effective clinical outcomes." (p.95)

National Audit Office Report of MoD: Treating Injury and Illness arising on Military Operations (2007)

• The recent report by the National Audit Office (NAO) to assess the effectiveness of the MoD's provision of medical care to Service personnel who were injured or suffered health problems (mental or physical) resulting from operations in Iraq and Afghanistan focused on the:
  • level of medical care provision in terms of:
    • timeliness
    • adequacy
    • availability
  • impact of minor injuries and illness on operational capacity (as measured by "manpower days lost")
  • effectiveness of medical support provision in terms of:
    • success of treatment in saving the lives of seriously injured Service personnel;
    • speed of evacuation from theatre back to the UK;
    • capability of the field hospitals to stabilise major trauma casualties, and
    • capacity of UK-based medical care and rehabilitation provision.
• The effectiveness of mental healthcare provision was examined in terms of:
  • trends in overall rates of mental health conditions during and after deployment,
  • balance of healthcare at three sites of delivery (i.e., forward bases, the field hospitals, and in the UK), and
  • mental health support for Service personnel on operations.
• To generate the necessary data pertaining to the aspects listed above, the methods underpinning the fieldwork for that report comprised the following seven elements.
  • Review of key documents - to identify the standards of medical care set by the MoD and to adjudge performance accordingly.
  • Semi-structured interviews - to enable an understanding of the delivery of treatment and rehabilitation and health protection measures.
  • Analysis of medical data - to permit analysis of rates of disease and injury and to create treatment pathways.
  • Other data analysis - to examine potential issues pertaining to capacity at medical facilities.
  • Process mapping and modelling - to ascertain any changes to treatment and rehabilitation and risks to capacity at Selly Oak and Headley Court.
  • Literature review - to compare the MoD care provision to identified good practice by analysis of the academic literature in the treatment and rehabilitation of:
    • major trauma;
    • post-trauma mental health;
    • musculoskeletal injury, and
    • gastrointestinal illnesses.
  • Focus groups - to solicit the patient perspective on care provided at Headley Court.
• In line with the report by the Healthcare Commission, the findings of the NAO evaluation suggested that there has been a steady increase in Service-related illness and injury rates in comparison with the data for 2001 (when the level of injury and illness rates on Operation HERRICK were at zero). In 2009, 131 Service personnel had suffered serious injuries on deployment. As the figures for Operation HERRICK have increased over time, the figures pertaining to Operation TELIC have gradually decreased from the highest rate of 46 in 2003 to the lowest rate of 1 in 2009. Both sets of figures however are likely to be an underestimate given that the data for 2009, based on recorded medical attendances on military operations, were only available up to 31 October 2009. Relative to the number of serious injuries sustained on Operation HERRICK and Operation TELIC, a considerably higher rate was reported for the total level of minor injury and illness. In 2009, the combined rate for both operations suggested that the health of 31,687 Service personnel had been compromised to some extent, although this was less than that reported in 2007 (n=38,419) and 2008 (n=47,035).
• As has been the case with the increase in the level of serious injury, the numbers of Service personnel with mental health conditions have increased since 2006 from 45 to 380 in 2009 for those deployed on Operation HERRICK. However, although the 2009 level (n=199) is higher than that of the 2006 level (n=74), there has been a decrease when compared with the previous two years of 2007 and 2008 (n=298 and n=239 respectively).
• The quality of operational medical care was evaluated by calculating the number of "unexpected survivors" (i.e., personnel who survived even although the severity of injury would be expected to have resulted in fatality). By means of mathematical modelling, the MoD identified 144 unexpected survivors who, when pooled with cases identified by clinical peer review between April 2006 and July 2008 among casualties treated at UK-run field hospitals, increased to a total of 175 (representing 25% of all seriously injured casualties who survived). In comparing this rate with the 6% of unexpected survivors rate achieved by 81 NHS hospitals (in England and Wales) based on Trauma Audit and Research Network performance data, the evidence supports the view of the Defence Committee Review and the Healthcare Commission (Defence Medical Services: A Review of the Clinical Governance of the Defence Medical Services in the UK and Overseas, March 2009, Commission for Healthcare Audit and Inspection) that the quality of healthcare provided on military operations is not only high confirmed by the views solicited, but it can also effectively reduce the risk of mortality. However, it is important to be aware of key differences in the calculations effected between the MoD and the NHS, the reasons for which will be addressed in Section 6.
• The increase in casualty rates overall combined with the increase in the number of "unexpected survivors" has inevitably resulted in an increase in demand for medical treatment and care. This currently has implications for field hospitals in Afghanistan (which are currently close to capacity in coping with casualty levels), the timeliness of evacuation (both to field hospitals and to the UK), contingency plans for capacity at Selly Oak, and impact on future Regional Trauma Networks (RTNs). With regards to the last named, research in civilian healthcare has shown an association between survival rates and the number of trauma patients seen by a clinician. The intention by the NHS to introduce RTNs (i.e., where a hospital in each region is an identified major trauma centre) requires the MoD to give careful consideration when planning new military hospital unit contracts to ensure a balance between military medical staff receiving sufficient experience of major trauma and the wider skills required for future operations and the NHS deriving benefits from that military trauma experience.
• In terms of rehabilitation, Headley Court was regarded as providing a unique facility for complex trauma, neurological injury and other complex injuries that is not currently matched by any NHS equivalent for general rehabilitation for trauma. This lack of a civilian equivalent combined with the paucity of data collated on outcomes for individual patients treated at Headley Court however means that it is currently not possible to benchmark the quality of care provided. However, there is a consensus of agreement by patients and military commanders that the quality of care provided by the mental and occupation health specialists and rehabilitation staff at Headley Court is "exemplary" as evidenced by the outcome of the independent Healthcare Commission review.
• Limitations in the data collected on operations (due in part to the difficult circumstances) mean that the MoD does not have any knowledge of how many personnel seek treatment (on demobilisation) at UK-based medical facilities for minor injuries or illness caused by military operations. To this end, it is not possible to: (i) quantify the full impact of military operations on the health of Service personnel, and (ii) accurately attribute the health burden of serving on operations. Thus, the opportunities for prevention may be severely compromised. To date, there are also no comparative data on illness and injury rates with coalition partners to assess relative performance. Because data sets are not linked, it is also not possible to monitor timelines for treatment and rehabilitation.
• Examination of the provision and use of military mental health services showed that a relatively low proportion of Service personnel are referred to specialist psychiatric support in theatre. Based on the first assessment by a mental health specialist, in 2008 the overall mental health rates for deployed and non deployed personnel who sought medical help in the UK were 16 per 1,000 of the population. The rate of PTSD assessed in the UK in previously deployed Service personnel was 1.1 per 1,000 personnel compared with 0.3 per 1,000 Service personnel who had never been deployed. In light of evidence that suggests that it can take a number of years before help is sought for mental health problems (e.g., Creamer & Forbes, 2004; Combat Stress, 2007) the full extent of the mental health problems associated with Operation TELIC and Operation HERRICK may not have fully emerged. Although Headley Court routinely assesses the risk of mental health problems in seriously injured personnel, there is no routine assessment of the mental health of other UK military personnel returning from operations.

5.2.3 Transition

National Audit Office (2007)

• In 2007, the NAO undertook an examination of the resettlement support provided by the MOD to Service leavers on discharge from all three Services. This examination sought to determine to what extent the following four areas of resettlement support optimised the opportunity for the successful re-integration of Service leavers into civilian life.

• (i) Career transition services
• (ii) Housing services
• (iii) Financial briefings and services for those who are being medically discharged
• (iv) Co-ordination of transition services and the communication of their nature in a timely and effectively manner.
• Data were obtained from the following sources.
  • A retrospective questionnaire survey - to obtain the views of 4,997 personnel who had left the Services in the two years prior to October 2006. (In total, the survey was sent by post to 38,153 Service leavers and achieved a 13% response rate.)
  • Semi-structured interviews - to obtain the views of key individuals and organisations within the MoD involved with the delivery of resettlement support to Service leavers.
  • First and second line visits to units in the three Services - to gain: (i) a better understanding of the practical delivery of resettlement services; (ii) insight into the key issues, and (iii) views on key issues arising from the survey (which included completion of a short questionnaire by second line officers).
  • Focus groups - to obtain views on the main issues addressed in the survey. (These involved 10 to 15 Service leavers at the units visited and the CTP centres.)
  • Financial and statistical analysis - to calculate the costs to the MoD of resettlement activities for 2005-06 and 2006-07. (These costs took into consideration each tier of the resettlement process, viz, outflow rates from the UK Armed Forces, CTP take-up rates and satisfaction rates, and subsequent employment statistics.)
  • Review of MoD papers - to evaluate policy and planning related to resettlement services and accommodation, performance CTP reports, minutes of resettlement conferences, guidance manuals and promotional literature. (This also included an examination of the Continuous Attitudes Survey conducted by the MoD in 2007.)
  • International comparisons - to understand how other countries (Australia, Canada, France, Germany, New Zealand and the USA) provide resettlement services. (That work benefitted from the availability of information obtained as part of the "Sustaining the Veteran" research project conducted by SCS Ltd for the UK Defence Academy.)

In addition to the above, the survey team attended some resettlement courses, workshops and briefings provided for Service leavers. The key findings pertaining to the evaluation of the effectiveness of the Career Transition Services are provided in Table 8.

• In interpreting those findings, however it is important to bear in mind the following.
  • Low response rate: For this reason, the extent to which these findings would be generalisable to the target population (i.e., Service leavers) is highly questionable. In view of the fact that it is not possible to establish the extent to which those who responded differed from those who did not, there is a potential for a response bias whereby those experiencing problems post discharge and/ or those with less favourably disposed towards the resettlement services would be least likely to respond. Alternatively, the reverse could also be true such that those who were most disaffected would relish the opportunity to respond in a critical fashion. Given that most of the responses received were more positive than negative and that the response rates were skewed in favour of those of a higher educational status (as evidenced by the higher response rate achieved for officers of all three Services) and discharge because of end of engagement (rather than medical discharge or compulsory/administrative discharge), it is more likely to be the former rather than the latter. Yet it is the views of those individuals who are most at risk of encountering problems that are particularly important in terms of helping to prevent subsequent problems of social exclusion.
  • Unweighted data: The data were not weighted to remove known biases relating to gender, rank, Service, and ethnicity as it was not possible to weight the data for other unknown biases associated with homelessness, literacy levels and educational status. For this reason, no attempt was made to extrapolate the results of the survey across the population.
  • Retrospective assessment: The reliability of the responses may have been compromised by recall bias due to the fact some respondents would have left Service up to two years previously. Given the difficulties in obtaining up to date contact details this retrospective census of all personnel leaving Service during the last two years prior to October 2006 was adopted for pragmatic reasons.
• The challenge associated with tracking Service personnel once they have been discharged from the UK Armed Forces (as highlighted initially by Dandeker et al 2005 with regards to identification of homeless ex-Service personnel) was endorsed further. Contact details of the Service leavers who participated in the NAO survey were dependent on those held by the MoD. Given that it is the responsibility of individuals to notify the MoD of any subsequent change of address once discharged, a proportion of the contact details were found to be no longer be valid; a situation which is likely to exacerbated to a greater extent in respect of the more vulnerable Service leavers.
• In respect of establishing overall value for money, the extent to which the NAO analysis could be performed in some areas was compromised because of the lack of pertinent information. Although the survey found that the MoD has "sound" management information on almost all aspects of performance (particularly the CTP contractor), it also reported that there is a paucity of data available for a number of aspects including the performance provided at single Service level (most notably at Army Unit level) and Service leaver's time spent on resettlement activities. Estimates were therefore calculated in respects of the following costs.
  • Cost to the MoD of time allocated to Service leavers to undertake resettlement activities by means of GRT is in excess of £78 million per year.
  • The overall cost of resettlement in 2006-07 was £115 million.
  • The MoD saves approximately £40 million per year in recruitment and initial training costs for those who start the CTP resettlement programme but who subsequently decide to return to Service (although it is difficult to attribute the relative influence of the advice provided by the CTP in this respect).

Table 8. Key Findings by Domain

Domain	Key findings
Effecting a successful transition	Approximately 75% reported that they found the return to civilian life as expected or easier. (Those who served the shorter time experienced most difficulty in making the transition.) Over 50% had a job to go to on discharge. Approximately 66% found military service of benefit in finding employment post-discharge. Only 10% took more than four months to find a job.
Employment status post-discharge	At the time of the survey, the majority of respondents were in paid fulltime work including 62% of Early Service leavers. Overall, only 6% were unemployed and seeking work.
Employment stability post-discharge	Approximately 33% of Service leavers had two or more jobs since leaving the services. The decision to change civilian jobs was mainly due to better pay and more responsibility.
Employment area	Over 50% had a job in the public sector.
Housing	89% of officers owned a house prior to leaving the Services (either outright or with a mortgage) compared to 25% of the junior ranks. On leaving the Services, the majority of officers and Senior Ratings resided in their own home whereas the majority of junior/other ranks were dependent on relatives for accommodation. Only 5% reported occupation of Service accommodation after their final day in the UK Armed Forces.
Debt	11% reported problems with debt pre-discharge. 13% encountered debt problems post-discharge. For those who experienced debt, the level of debt for most was under £5,000 (both pre- and post-discharge).
Civilian GP registration	12% were not currently registered with a civilian GP.
CTP services use	9% of entitled Service leavers did not make use of the CTP resettlement package. The main reasons for officers not doing so pertained to the view that attendance at the CTP would not be useful or relevant to the needs of the individual and to a lack of awareness of the CTP services. Those respondents who had served as NCO/Warrant Officer/ Senior Rating were most likely not to attend because they waived their entitlement in exchange for a reduced notice period.
Satisfaction with CTP services	Of those entitled to the CTP, most were satisfied with a number of the elements of the employment support provided.

5.2.4 Homelessness

Dandeker et al (2005)

• As part of a wider UK study of ex-Service homelessness, the MoD and the Office of the Deputy Prime Minister (ODPM) commissioned the King's Centre for Military Health Research (KCMHR)^[146] to undertake a feasibility study to:
  • examine and develop methods to be used in a future study regarding the extent, nature, and costs of rough sleeping and homelessness among ex-Service personnel in England.
• The UK literature review conducted by Dandeker et al (2005) highlighted the paucity of studies on ex-Service homelessness in the UK. Moreover, of those undertaken, almost all have been based on small sample sizes^[147] and have been predominantly London-based. The review of the international literature confirmed that most of the international literature had emanated from the USA. To this end, it further endorsed the limitations in making direct comparisons due to major differences in the provision of:
  • health and support systems;
  • the length of time that ex-Service personnel can access services post-discharge, and
  • the type of outreach services, and the provision of medical and addiction treatment services.
• Dandeker et al (2005) also identified two groups who were most at risk of homelessness and other related difficulties post-discharge, as follows.

Group 1: Service personnel who left Service early by virtue of either: (i) failing to pass their basic training; (ii) administrative discharge, or (iii) medical discharge.
Group 2: Service personnel who served for a number of years without difficulty, but who experienced problems of adjustment in making the transition from military to civilian life.

• Comparisons undertaken between the 33 ex-Service personnel and the 22 civilians who participated in these interviews showed key differences in respect of the circumstances listed below.
  • Age - ex-Service personnel were older.
  • Encounters with the Criminal Justice System - ex-Service personnel reported more arrests before the age of 15 years, but civilians were more likely to have served time in prison or a young offenders institution and to have committed more offences (including theft, possession of firearm, and robbery).
  • Physical health problems - ex-Service personnel were more likely to report problems although Dandeker et al (2005) suggest that this may be because of better access to healthcare services or a reflection of the age difference.
  • Foster care - civilians were more likely to report experiencing foster care. Relatedly, civilians were also more likely to report a dysfunctional family background.
  • Substance misuse - civilians were more likely to report problems with alcohol and drugs. However, Dandeker et al (2005) suggest that this may be due to enhanced access to healthcare and/ or a reflection of the age difference between the two groups. It may also however be a matter of "definition".
• Of particular relevance to our scoping review are the two aspects of the Dandeker et al (2005) feasibility study that relate specifically to Scotland. The first relates to the comprehensive review of the key methodological issues that would need to be considered in the event of a larger study and the implications that these would have should a similar endeavour be commissioned in Scotland. These particular issues will be discussed in Section 6. The second pertains to the findings from the pilot interviews conducted in Scotland (presented below) to give an in-depth understanding of the unique characteristics of this particular group and to explore some of their pathways to homelessness.
• In terms of the pilot interviews conducted in Scotland, these were based on a sample size of 15 ex-Service personnel from Edinburgh (n=11) and Glasgow (n=4). The majority of the sample were identified as having:
  • served in the Army (n=13);
  • seen active service (n=10);
  • completed their period of engagement (n=6);
  • not received a Resettlement Package prior to leaving service (n=13);
  • become homeless due to family breakdown (n=8), and
  • spent their first night on leaving the Service in a family member's home (n=8)
• The majority (n=9) felt that their time in the military had "helped". Only three considered that the military had "disadvantaged" them even although six had reported the reason for leaving the UK Armed Forces as either "dishonourable discharge" or "medical discharge". The mean length of service was 7 years (range of 1-22 years). Based on qualitative data obtained from 15 ex-Service personnel, the vulnerability factors that emerged pertained to the following four circumstances, as listed on p.92.
  • "Unstable family life, especially divorce or relationship breakdown"
  • "Inability to adjust to civilian life"
  • "Dishonourable or medical discharge"
  • "The belief that they had not been given sufficient support on leaving the Armed Forces"

5.2.5 Health and Social Outcomes/ Health Services Experience

Fear et al (2009b)

• Commissioned by the Department of Health in England, the report by Fear et al (2009b) summarises the available evidence on the: (i) health and social outcomes, and (ii) health experiences of ex-Service personnel of the UK Armed Forces. As such, their focus was predominantly on those who had left Service rather than those who have been Veterans of a specific conflict or war, but who remain in Service.
• The authors of this report highlight the fact that the military-related literature uses the term "Veteran" in two different ways. Some studies use the term to refer to those military personnel who are no longer serving having left the military. Other studies use the term to refer to those military personnel who remain in Service but who have been operationally deployed in support of particular conflicts or wars (e.g., Gulf War Veterans). Relatedly, they also raise the issue of the different definitions attributed to "Service" and the extent to which it can vary among nations. A detailed explanation of the differential use of both of these terms has been addressed by Dandeker et al (2003, 2006).
• In extending the original review of the literature undertaken by Dandeker et al (2003), the more recent review focused on papers published since 2003 to provide a general overview of the national and international literature on the health and social outcomes, and health services experiences, of UK ex-Service personnel. The 76 papers selected as being of most relevance to ex-Service personnel were categorised according to four categories, the description for which along with the number identified per category is presented in Table 9.

Table 9. Categorisation, Inclusion Criteria, and Numbers Identified Per Category (N=76)

Coding	Category	Inclusion Criteria	Number Identified n
1	"Ex-Service personnel UK"	Includes some data on UK ex-Service personnel Not necessarily the focus of the paper	24
2	"Service personnel in general (UK)"	Includes data on UK Service Personnel Not specific data or analyses on ex-Service personnel	21
3	"Ex-Service personnel (non-UK)"	Includes data on non-ex-Service personnel Can be applied to UK ex-Service personnel	9
4	"Service personnel in general (non-UK)"	Includes data on non-UK Service personnel Has relevance to UK ex-Service personnel	22

• The key findings identified by Fear et al (2009b) are summarised in Table 10 below. On the basis of those findings, a number of recommendations were made for future research endeavours to investigate issues for which questions which have yet to be addressed in respect of health and social outcomes of ex-Service personnel in the UK. These included the need for periodic review of that evidence and the need for researchers to use different study methods and designs in order to achieve the following.
  • Longitudinal, prospective studies to enable the stratified follow-up of a sample comprising ex-Service personnel. To facilitate the conduct of such studies, however, would require:
    • obtaining consent at either the time of recruitment, during military Service or on discharge;
    • planning to ensure data collection commences prior to the occurrence of adverse outcomes either whilst military personnel are still serving or after they have left Service.
    • using data linkage of routinely collected data to facilitate a systematic method of data collection and collation.
• Randomised controlled trials as an evidence-based approach to determine the efficacy of interventions, including those used for screening purposes, and to facilitate the standardisation of mental health care provision.
• Qualitative studies to enable an in-depth exploration of complex issues (e.g., the transition from military to civilian life), which cannot be readily understood when relying solely on quantitative research methods.

Table 10. Key Findings According to Focus of Analysis

Focus of Analysis	Key Findings
Comparisons of UK ex-Service population with general population.	Similar in health status Broadly similar prevalence rates of mental disorder Similar rate of suicide (except for male ex-Service personnel aged 24 years or less, who are at increased risk compared to similarly aged males in the general population)
Comparisons of UK military personnel (Service and ex-Service) with general population.	Higher alcohol consumption in UK military personnel, but this difference does reduce with age
Comparisons of ex-Service personnel with members of the UK Armed Forces who are still serving.	Similar prevalence rates of mental disorders
Comparisons of UK military personnel affected by mental health problems with UK military personnel without mental health problems.	Military personnel affected by mental health problems are more likely to: leave Service early experience adverse health and social outcomes post-Service
Military personnel who leave Service with psychiatric problems	Increased risk of: social exclusion ongoing ill health
Comparisons of early Service leavers with longer serving UK military personnel.	Early Service leavers are more likely to be at risk of: developing health problems engaging in risk taking behaviours
Gulf War deployment	Associated with: increased mortality from non-disease-related causes (in particular road traffic incidents), but effect reduces over time such that by 7 years post-deployment it cannot be observed Not associated with: reproductive health problems an increased incidence in cancer
Deployment to Iraq/ Afghanistan	Associated with adverse mental health outcomes in respect of military personnel who: report pre-Service vulnerabilities serve as a Reservist (when compared with their Regular counterparts) report high levels of direct combat exposure USA data on returning US military personnel suggests an ongoing increase in mental health problems - no evidence has been found to suggest that this is the case for the UK.

5.2.6 Community-Based Mental Health

Dent-Brown et al 2010

• Funded by the UK MoD in collaboration with the Health Departments for England, Scotland, Wales and Northern Ireland, six regional community mental health service pilots for UK Armed Forces Veterans^[148] were evaluated by means of a comparison with three existing services, viz, Combat Stress, Humber Traumatic Stress Service (NHS) and UDR/Royal Irish Aftercare Service. The project team was led by Dr Kim Dent-Brown of the University of Sheffield and the evaluation was supported by a number of key individuals in its design and implementation including Professor Ian Palmer (MAP) and Dr Anne Braidwood (MoD).
• The key objectives of this endeavour were to evaluate service provision in terms of identifying facilitators and barriers in order to address the question as to "what an effective, culturally sensitive, cost effective and sustainable NHS led mental health service for Veterans would look like". Each service differed in respect of design, availability of resources and funding, as well as the envisaged service model of care.
• A multi modal method was used to obtain data from each service in respect of:
  • clients (routinely collected and anonymised data; anonymised questionnaires);
  • lead clinicians/managers (telephone interview);
  • staff (sample diary activity), and
  • documentary evidence (annual reports and the outcome of audits).
• The extent of data collection across the pilot services varied considerably. The findings for all services were based predominantly on the questionnaires returned by a small subsample of clients with an average response rate of 8%. For this reason, statistical analysis of the data was not possible. In addition, it is important to note that the majority of respondents were aged 40 years and above and had been discharged from service between 10 to 20 years previously. Consequently, the authors emphasise that the accounts provided may not reflect the current practice in the MoD, UK Armed Forces or NHS. However, some conclusions were drawn about the more and less successful features of the pilot services, as shown in Table 11. (These, however, did not include an evaluation of generic services [i.e., those for non-Veterans].) As post-intervention outcome data were only collected by one service, conclusions about Veterans' perceived acceptability of and satisfaction with services was based on qualitative data.
• Eight priority recommendations were made such as the need for a common minimum data set to be established for enabling inter-service comparisons and co-ordinated by an independent research group. This would include routine pre- and post-intervention outcome data for all clients seen. Further recommendations were made in respect of: the identification and accessibility of mental health services for Veterans; staffing and activity levels, and the need for strategic investment in enhancing data collection practices by co-ordinating computerised patient information systems with that of the NHS.

Table 11. Pilot Services Evaluation by Components

More successful features

Less successful features

option of self-referrals access to staff with experience of being a Veteran staff with training and experience of working with Veterans availability of group work with other Veterans provision of multi-agency clinics to advise on health, psychosocial and financial issues services with combined assessment and treatment to reduce waiting time teams/buildings identified as being specifically dedicated to Veterans conjoint agency working and sharing of information routine access to the UK Armed Forces' service records of new referrals

reliance on assessment-only services resulting in treatment in generic NHS settings clinical pathways that involve onward referral with subsequent waiting lists staff who lack training and experience with Veterans sole practitioner services resulting in discontinuity of care Veterans required to travel long distances for assessment/treatment

• The one Scottish based community pilot, Veterans' First Point (V1P), comprised a "one-stop shop" for Veterans and their families, the concept for which was established in 2007 and based on a mental health service to provide information and support on a wide range of health and social welfare issues. The model took two years to develop, and NHS Lothian applied to run the pilot with additional funding from the Scottish Government. A key feature of the service was that the core staff (three peer supporter workers and a full time Veterans Therapist) were all ex-Service personnel and all employed staff were NHS employees. The service began accepting referrals on the 23 April 2009, and during the MoD funded period, at total of 291 referrals were received of which 111 attended an appointment with a clinician. A comparison of these referrals with Combat Stress (and to some extent Northern Ireland) showed differences in respect of marital status, service, time served and rank, as follows.
  • Higher rate of divorce for Lothian referrals of 39% compared with 27% for Combat Stress and 13% for Northern Ireland;
  • Smaller proportion of Army referrals (77.4%) and a higher proportion of RAF (9.7%) and Royal Marines (2.8%) for Lothian compared with Combat Stress (82.4%, 4.3%, and 0.3% respectively);
  • Higher proportion of Lothian referrals had served 0-4 years (30.6%) and fewer over 10 years (31.1%) than Combat Stress (12.7% and 48.7% respectively), and
  • Higher proportion of Lothian referrals were Privates (65.4%) than Combat Stress (42.6%).
• Data were obtained for 30 clients seen by V1P in respect of initial severity and outcomes, viz, the PHQ-9^[149] and the WSAS^[150]. A comparison of intake scores for Lothian, Combat Stress and Northern Ireland showed that, although the WSAS scores were similar, those clients referred to the two pre-existing services reported slightly more mood disturbance symptoms than did the clients of V1P. However, no outcome measure data were available to ascertain whether scores changed post-treatment.
• Whilst the median satisfaction score for Lothian was slightly higher than that of Northern Ireland (31.1 vs 27.5 respectively), this was based on responses received from only 13 clients out of the 160 questionnaires distributed (i.e., a response rate of 8.1%). Of the six community mental health pilots for Veterans, however, the Lothian service did receive the highest rating with regards to:
  • welcoming environment;
  • staff familiarity with UK Armed Forces culture and experience;
  • choice of support on offer, and
  • enhancement of client's situation^[151]

5.3 VETERAN-RELATED CHARITIES AND AGENCIES COMMISSIONED STUDIES

Table 12. Summary of Veteran-Related Charities and Agencies Commissioned Studies

Year	Title and Source
Veterans' Profile and Needs: UK
2005 2006 2006 2006 2006 2011 2011	"Profile of the Ex-Service Community in the UK" (Compass Partnership, The Royal British Legion) "Profile and Needs: Comparisons between the Ex-Service Community and the UK Population" (Compass Partnership, The Royal British Legion) "Greatest Welfare Needs of the Ex-Service Community" (Compass Partnership, The Royal British Legion) "Profile and Needs of the Ex-Service Community 2005-2020" (Compass Partnership, The Royal British Legion) "Future Profile and Welfare Needs of the Ex-Service Community" "Health, Welfare and Social Needs of the Armed Forces Community: a Qualitative Study" (Compass Partnership, The Royal British Legion) "Legion Welfare in the 2010s: A Decade of Change" (Centre for Future Studies, The Royal British Legion)
Veterans' Profile and Needs: Scotland
2005	"Meeting the Need. A Report into Addressing the Needs of Veterans Living in Scotland" (Poppyscotland)
Treatment Effectiveness and Client Satisfaction Evaluation
2007	"Combat Stress: Treatment Effectiveness and Client Satisfaction" (Hart & Lyons, Combat Stress)
2009	"An Evaluation of the Gardening Leave Project for Ex-Military Personnel with PTSD and Other Combat Related Mental Health Problems" (Atkinson, The Gardening Leave)
Service Provision Evaluation
2012	"Armed Services Advice Project Evaluation" (Bonnar Associates, Poppyscotland)
Homelessness
2008	"The Experiences of Ex-Service Personnel in London" (Johnsen et al, The Ex-Services Action Group)
2009	"Review of Data from Scottish Government. Ex-Service Personnel Making Homeless Applications" (MRUK Research, Poppyscotland)
Employment
2009 2009	"Research into Good Practice in Supported Employment, and Identification of Key Resources" (Hurley & Simpson, Poppy Scotland) "Research into the Employment Needs of Disabled and Vulnerable Veterans in Scotland" (Hurley et al, Poppyscotland)
Criminal Justice System
2008	"Ex-Armed Forces Personnel in the Criminal Justice System" (National Association of Probation Officers [NAPO])
2009	"Armed Forces in the Criminal Justice System" (National Association of Probation Officers [NAPO])

5.3.1 Veterans' Profile and Needs: Scotland

Poppyscotland (2005)

• In December 2005, the Earl Haig Fund Scotland (EHFS) Board of Directors approved the implementation of the Alfred Anderson Plan^[152]; a 12 month strategic review which included as its first step the need to conduct research to:
  • clarify the extent of current needs in the Veterans' community in Scotland, and
  • identify which needs the EHFS should support.
• The rationale for this strategy related to the fact that because the size and nature of the Veterans' community in Scotland will change over time, it is imperative to ensure that ex-Service organisations can: (i) accommodate any change in needs, and (ii) deliver support in a way that is both efficient and cost effective. To this end, the then Chief Executive of Poppy Scotland (Major Jim Panton^[153]) referred to two significant challenges in particular facing ex-Service organisations over the next decade, viz, ensuring:

(i) effective communication of the on-going development of appropriate services, and
(ii) that service provision meets the current needs of the Veterans' community.

• Under the direction of Mr Gary Gray (Head of Charitable Services) the research programme comprised the following four phases.
  • Phase 1 - interviews with over 30 ex-Service organisations to identify collective support available to the Veterans' community.
  • Phase 2 - face-to-face interviews with Veterans and their dependents throughout Scotland (commissioned as an independent research project which was conducted by George Street Research)
  • Phase 3 - analysis of the information from individuals and organisations within the Veterans' community.
  • Phase 4 - formulation of recommendations for consideration by the EHFS Directors.
• The outcome from Phase 1 was the identification of a host of varying levels of activity, which included the delivery of advice to Veterans at a local level, "caseworking" and the provision of "benevolence". A total of 15 "lead" organisations^[154] were identified, the majority of which support the delivery of "local initiatives" (n=12)^[155] and provide "benevolence" (n=12)^[156]. Local initiatives comprise a wide range of activities (including hospital visits) considered to play an essential role with regards to:
  • identifying those Veterans who are in greater need (e.g., due to unemployment), and
  • instigating referrals to appropriate agencies depending on the nature of their needs.
• Reasons for support, however, were found to vary considerably and were not dependent on age (although those who were younger and older were most likely to require such support). In respect of the older generation, difficulties commonly encountered related to the physical demands in undertaking routine tasks.
• Provision of financial support by means of "one-off benevolence grants" fell predominantly on the single-Service Benevolent Funds, EHFS, OAS and Regimental Associations. SSAFA Forces Help played a key role in negotiating with grant giving bodies to obtain financial assistance as and when required.
• Analysis of the needs of EHFS clients over a 12 month period by means of FY03/04 based on demographic characteristics, type of support received, and cost of support provided, indicated that the majority (75%) were aged 50 years or more thereby reflecting the RBL profile of the UK Veterans' community of November 2005. In addition, it was suggested that this finding has important implications in light of increases in life expectancy such that it may well be the case that the demand for benevolence support provided by ex-Service organisations will persist for some time to come. The population projections estimated for Scotland bear further testimony to that view. These suggest that, by 2031, there will be an 81% increase in the proportion of people aged 75 years. Those who are over 65 years of age will constitute 24% of the Scottish population (Anderson et al, 2008b).
• In anticipation of an increase in the number of elderly Veterans in the Scottish population^[157], emphasis was also placed on the need for the continued provision of residential, nursing and dementia care. A key aspect of that provision, however, was the need to ensure "…cooperation, collaboration and rationalisation that could be replicated in other areas of the Veterans Scotland arena". (p.8) On this basis, the gradual withdrawal of some organisations in delivering this type of care (e.g., the sale of Flanders House^[158] to Erskine by EFHS in October 2005) was considered to be a "sensible" development.
• Emphasis was placed on the need to retain services offered by ex-Service organisations not being catered for by the NHS or Social Services. Combat Stress was specifically mentioned in this regard. However, in view of the considerable number of organisations that provide a wide variety of support to Veterans throughout Scotland, the Poppyscotland report proposed rationalisation as a strategy to streamline service provision to maximise the effective use of resources. This is particularly the case where areas of duplication exist such as that found in relation to some of the functions undertaken by the RBLS Pensions Department^[159] and the War Pensioners' Welfare Service (WPWS)^[160]. On this basis, it was suggested that the formation of stronger working practices between these two organisations may result in a better use of the WPWS as a publicly funded body.
• The following three specific factors were highlighted with regards to considering the provision of pension support by ex-Service organisations:

(i) Mortality: This has resulted in a substantial reduction in the number of war pensioners resident in Scotland (as well as the rest of the UK).
(ii) State provision: The improvements of the provision of state benefits may deter those entitled to a war pension for fear of jeopardising their state entitlement.
(iii) Armed Forces Compensation Scheme: Following its introduction in April 2005 and the implementation of the recommendations from the recent Armed Forces Compensation Scheme Review (MoD, 2010), there will be an inevitable reduction in the number of applications for war pensions from new Service leavers.

• The need to ensure a co-ordinated approach across all aspects of service provision featured heavily in the Poppyscotland report. Veterans Scotland^[161] in particular was considered to have made significant progress in terms of modernising the way in which housing organisations work in partnership. As a potential model for replication elsewhere in the UK, examples of the housing initiatives implemented by Veterans Scotland to facilitate this partnership included the:
  • launch of a new website launched to help ex-Service people applying for Veterans' housing anywhere in Scotland.
  • development of the Combined Housing Register (CHR), which finds accommodation best suited to Veterans' needs with rent cheaper than normal rent arrangements.
  • enhancement of the application process to allow Veterans to express an interest in a suitable area by clicking on a map and browsing all properties currently available.
  • standardisation of the housing application form which is subsequently validated by Veterans Scotland prior top the request for accommodation being placed on the active list until suitable accommodation is found.
• Specific reference was made to the importance of addressing the issue of homelessness among ex-Service personnel in Scotland. The potential for Veterans to become homeless in Scotland was heightened by two factors in particular. First, general housing demand was considered to exceed housing supply. Second, different qualifying criterion for eligibility in terms of the 900 accommodation units was identified. On the grounds that most of that population are located in Glasgow, it was proposed that future endeavours in this regard should target that region and involve the key homelessness organisations to establish how best to proceed in the future. In addition to undertaking discussions with the Glasgow Homelessness Network (GHN), suggestions for possible future initiatives included the formation of a Scottish equivalent of the London-based ESAG and Project Compass. However, prior to doing so, Poppyscotland recognised the importance of conducting further research amongst the homelessness in Glasgow to establish whether there would be a justified requirement for such initiatives.
• Homeless Veterans were also considered to have a greater need for enhanced employment advice and support than the majority who effect a successful transition from military to civilian life. In addition to addressing these needs, further exploration was also suggested with respect to the employment needs of disabled Veterans.
• In an endeavour to solicit empirical evidence of the needs of Veterans in Scotland, Poppyscotland have been responsible for commissioning a series of research projects (as summarised in Table 11), which followed on from research undertaken by (George Street Research) to conduct face-to-face interviews with a sample of Veterans. Although it was not possible to obtain a copy of the report detailing the size of the sample and how that sample was identified, the key findings reported in Poppyscotland report entitled "Meeting the Need" were as follows.
  • Thirty five per cent of Veterans experienced some form of difficulty although most of those interviewed (94%) reported being "happy or satisfied with their life in general", and reported being "happy or satisfied with their life". Older respondents however were less happy or satisfied than the younger respondents.
  • Those who experienced most difficulty were 75 years of age and above (45%).
  • In terms of the most common areas of difficulties reported, these were related to the following issues.
    • Mobility (15%) - these were linked to age with 24% of those who reported difficulties with mobility being aged 75 years and above.
    • Financial (12%) - these were encountered by both the younger and older participants.
    • Self care/ wellbeing (9%) - these were mainly reported by the older respondents.
  • Less common were the difficulties arising from dysfunctional relationships (6%), employment (6%) and housing (5%).
  • Sixteen per cent of respondents had experienced two or more difficulties identified.
  • Although the overall level of awareness of the main ex-Service organisations in Scotland was high, of those respondents who were aware of the existence of these organisations, 60% had not made contact and 80% had not received support from them. Reasons for not making contact was due to the view that they either had no need to do so (70%) or had not experienced any problems (21%).
• Based on the outcome of the review of current support provision and the research undertaken by George Street Research, a gap analysis was undertaken to compare the current provision of support with that of the expectations of Veterans. One of the key areas identified was the absence of a specialist service that could deliver a single point for providing advice to the Veterans' community in Scotland. To this end, Poppyscotland proposed the establishment of a:
  • regional high profile one-stop advice centres where Veterans could receive advice and support that would encompass the full range of their specific needs;
  • national helpline;
  • website outlining the provision of support available to Veterans, and
  • portfolio of co-ordinated promotional material for wide distribution to raise awareness of the support available to Veterans and to other service providers (in both the voluntary and public sector). In addition, it was felt that this would also provide the opportunity to raise general awareness of the public in order to benefit future fund raising.
• Poppyscotland's Board of Directors agreed that Poppyscotland should proceed with establishing a pilot one-stop advice centre in Glasgow delivered by means of a designated telephone advice helpline with "active referral"^[162] to the local Citizens Advice Bureaux (CABx) or to telephone advice centres via Citizens Advice Direct (CAD). A Service Level Agreement between Poppyscotland and Glasgow Citizens Advice Bureau Consortium provided the operational guidelines for an "accelerated"^[163] pilot service, which was launched in August 2007 and comprised a consortium of eight CABx^[164].

5.3.2 Treatment Effectiveness and Client Satisfaction Evaluation

Hart & Lyons (2007)

• On the basis of recommendations made by the HACAS Review (2005) and by the Defence Committee Review (2006), Combat Stress commissioned a research study specifically designed to show evidence of treatment outcome in respect of those clients referred to one of their three treatment centres. In May 2007, Hart and Lyons produced the report of that study, the objectives of which were to examine the:
  • effectiveness of the residential treatment provided by Combat Stress in respect of contributing to the management of chronic combat-related mental health disorders, and
  • client satisfaction with treatment provision.
• Based on a convenience sampling design, potential participants were identified using the Combat Stress database, which was established in 2004 and constituted predominantly male Army Veterans between the ages of 40 and 50 years. The sample comprised 57 Veterans admitted to one of the three Combat Stress treatment centres ("Treatment Group") and 47 Veterans who were recommended for a first admission ("Control Group") resulting in a response rate of 53% and 48% respectively. Due to financial and temporal constraints, these two groups were not however matched for demographic variables although it was "…expected that both groups would reflect the demographic profile of the existing database" (p.17). Table 13 also shows the composition of the two groups was not markedly dissimilar. Furthermore, the two groups were not matched in respect of clinical presentations in view of their heterogenous nature comprising a variety of physiological and psychiatric diagnoses. On average the Treatment Group had had four previous admissions to the treatment centre whereas those in the Control Group had only received one visit from a RWO.
• To accommodate the diversity of clinical presentations of those Combat Stress clients who receive treatment, the General Health Questionnaire-28 item version (GHQ-28)^[165] was used as a self-report measure of general psychopathology to assess treatment outcome. A Client Satisfaction Survey was specifically designed to assess the extent to which the needs of clients were being met by the Combat Stress treatment centre. Having been piloted on 60 clients across all three treatment centres, the final version comprised a number of statements with Likert scale responses of 1-5 to measure the extent of agreement for each. Assessments were conducted at four weeks prior to admission of the Treatment Group (baseline), on discharge (midpoint), and at four weeks post-discharge (follow-up).
• A between-group comparison of the GHQ-28 scores at these three assessment points using non-parametric statistical methods (given the skewed distribution of the data for both groups) revealed that there was:
  • no significant difference between the two groups at baseline;
  • a significant improvement in GHQ-28 scores for the Treatment Group at discharge, and
  • no significant difference between the two groups at four weeks follow-up.

This finding highlights the fact that a major challenge of any therapeutic regimen is the durability of positive changes, which is a perennial problem for civilian clinical samples as well. Relapse can be too often the norm. There is a need, therefore, to find ways to sustain any initial positive treatment effects, and this would include identifying factors which either compromise or facilitate the durability of such effects.

Table 13. Profile of Combat Stress Sample

Characteristics	Treatment (n=57) %	Control (n=47) %
Gender: Male Female	100	94 6
Service: Army Air Force Marines Merchant Navy Navy	75 9 5 3 9	77 4 6 4 9
Source of referral: GVMAP NHS Other Relative/other client Self Service charity/ welfare organisation	4 16 4 5 48 23	- 17 - 23 34 26
Mean age:	50 years	46 years

• A high level of client satisfaction was reported across all three Combat Stress treatment centres in respect of the:
  • preparation for admission by the Regional Welfare Officer
  • admission process
  • practical care and therapeutic aspects of their admission
  • treatment centre staff
  • recreational activities offered during the residential stay
  • discharge procedure
  • aftercare provision
• The lowest satisfaction scores were reported in respect of symptom improvement; a finding which was attributed to:
  • how the questions were framed (i.e., participants were asked to consider changes in their symptoms rather than how effective they perceived their admission to have been in terms of symptom improvement), and
  • an incongruity between client expectations of complete symptom resolution versus the clinical reality that substantial improvements in chronic conditions is unlikely to occur over a two-week admission period.
• Whilst this study had a number of methodological limitations (as declared by the researchers), it represented a significant step forward for Combat Stress with regards to:
  • obtaining empirical evidence to demonstrate treatment outcome;
  • implementing a number of operational changes across the three treatment centres (e.g., standardisation of procedures, introduction of new practices, and the development of appropriate operational guidelines);
  • on-going progress towards a treatment-focused model, and
  • enhancing opportunities for future research.
• For the purpose of future research, Combat Stress has made a concerted effort to improve the quality of the clinical data captured as part of its routine clinical audits (information about which is provided by Fletcher [2007] and Busuttil [2008]). This includes the pilot of a new assessment procedure for first time admissions within two of the Combat Stress treatment centres; an endeavour that derived from the recommendations made by the HACAS Report (August 2005) and the subsequent Whole Person Plan (October 2006). In particular, this enhanced clinical database has the potential to benefit research on younger Veterans given reports of a substantial increase in referrals due to Op TELIC and Op HERRICK.

Atkinson (2009)

• In 2007, Gardening Leave was established as a horticultural therapy pilot project and hosted by Combat Stress at Hollybush House^[166]. It was designed as an adjunct to the standard therapies provided by Combat Stress in order to enhance the therapeutic experience of ex-Service personnel suffering from PTSD and other combat-related mental health problems. Residents of Hollybush House and non-residents (i.e., those within commutable distance) were able to attend Gardening Leave for either a whole or half day subject to their other therapeutic commitments and in accordance with their treatment plans.
• The principal aim of this pilot study was to evaluate the impact of Gardening Leave from the dual perspective of both service users and clinical staff and to ascertain why and in what ways. By means of a qualitative approach, a total of 44 face-to-face interviews were conducted with ex-Service personnel over a six month period from August 2008 to February 2009. The number of clinical staff interviewed is not evident from the report and no profile is provided for either group of participants.
• The report presents a brief summary of the preliminary findings which suggested that positive therapeutic benefits were derived by those who participated in Gardening Leave (particularly those with PTSD) for a variety of factors including: flexibility of and choice in participation; secure environment; ease of access; working outdoors; having a structure to the day, and sharing an exclusive experience with others who were suffering from the same illness. The positive benefits cited include: having a sense of purpose; regaining confidence; engaging in physical activity; developing transferable skills, and feeling understood. However, claims that "Gardening Leave is having positive therapeutic benefits….helping individuals to cope better…" would need to be substantiated by a more rigorous evaluative method and design than is evident from the report.

5.3.3 Service Provision Evaluation

Bonnar Associates (2012)

• Funded by Poppyscotland, the evaluation of the Veterans' advice service pilot was commissioned Glasgow CABx and undertaken by an independent research consultancy (Bonnar Associates). The first part of the evaluation was a baseline assessment conducted during June 2007 by CAD and six of the consortium members to identify the number of Veterans who were already seeking advice from the CABx service by asking every client to reply to the following three questions.

(i) "Have you ever served in the British Armed Forces?"
(ii) "Has your partner ever served in the British Armed Forces?"
(iii) "Has a member of your immediate family ever served in the British Armed Forces?"^[167]

• The baseline evaluation revealed that a very small proportion of clients who had contacted the CABx service during the June 2007 were Veterans. Of the 2,542 calls received by CAD, 18 (0.7%) were from Veterans, 16 (0.6%) were from partners of Veterans, and 123 (4.8%) were calls from close relatives.
• An active publicity campaign prior to and post-launch of the service resulted in 151 clients accessing the service over the 12 month evaluation period from August 2007 to July 2008. An analysis of the profile of these clients showed that the majority were:
  • Veterans (71%) of whom 84 % were from the Army;
  • from Glasgow (95%) (The majority (78%) of those with Glasgow postcodes resided within areas identified as the top 15% most deprived areas of Glasgow.);
  • living in rented accommodation (Local Authority [21%]; RSL [29%]; private [6%]);
  • single adults (58%);
  • retired (70%), and
  • physically disabled or had experienced either a chronic illness or mental health issues (66%) (Of the 122 for whom details were available, five had a disability related to their Service.)
• Based on data obtained from 58 clients, 93% had an income of less than £15,000 and 38% reported an income of less than £6,000. Most client needs were for advice on financial matters relating to benefits (29%) and consumer debt (25%). CABx service advisers were instrumental in assisting 37 clients with negotiating in excess of £550,000 worth of debt (i.e., £14,944 per client in debt which was more than of the average of £14,065 for the preceding year for all Glasgow CABx clients). In estimating the Client Financial Gains (CFG) using what data were available at the end of the pilot, the average of £898 for the Veteran pilot clients was considerably higher than the average of £336 for all Glasgow CABx clients in the previous year. In this regard, the Veteran pilot service was deemed to be "very successful".
• In terms of service provision, 151 clients made a total of 455 contacts with the CABx service; 17 home visits were undertaken, and 1,024 separate issues were dealt with. A total of 14 clients were referred to SSAFA Forces Help and two were referred to Poppyscotland for the purpose of obtaining financial assistance. The total cost of providing the Glasgow pilot was calculated as £100,611 for the 112 closed cases (i.e., £898 per client). With regards to service uptake, however, the numbers of Veterans accessing the service remained lower than anticipated (although there was no detriment in terms of value for money with respect to reduced bureau participation since payment was based on uptake).
• The research consultants rightly highlight the fact that the interpretation of the findings is confounded by a number of factors which derive in part from amendments to the wording of the third question from "Veterans' immediate family" to "Veterans' dependents". As such the validity of making direct comparisons between the baseline evaluation and the pilot evaluation was compromised because the eligibility criteria were not the same for both. Moreover, the lack of information for some aspects limited the extent to which it was valid to draw conclusions about the representativeness of the sample. No analysis was undertaken to establish to what extent the Veteran clients differed in respect of their needs to those of the civilian clients who contacted the CABx services during the pilot period. It is also not clear as to what was the proportion of the Veteran clients relative to the civilian users. However, in recognition that its purpose was to pilot a service to inform potential options, the outcome of the Glasgow CABx pilot has highlighted some important challenges facing the delivery of such a service on a national basis. These include the:
  • justification for providing a dedicated service for Veterans which is not embedded within a mainstream service given the relatively small number of Veteran client users;
  • potential ambivalence of other ex-Service organisations which may result in an unwillingness to co-operate;
  • importance of increasing awareness of a service by means of an active publicity campaign whilst taking into consideration the cost implications of mass marketing;
  • need to obtain high quality data to facilitate the analysis and ensure robust evidence;
  • consideration of how best to measure the effectiveness of a service bearing in mind the resource implications associated with obtaining hard evidence (e.g., by means of Social Return on Investment), and
  • need to ensure full co-operation from all agencies involved in providing the service.

5.3.4 Homelessness

Johnsen et al (2008)

• Commissioned by The Ex-Services Action Group (ESAG) on homelessness^[168], an independent study was conducted by the Centre for Housing Policy (CHP) at the University of York. Its two main objectives were to assess the:
  • scale and nature of ex-Service homelessness in London, and
  • impact of homelessness projects^[169] instigated by ESAG in an endeavour to reduce ex-Service homelessness in London.
• In fulfilment of these objectives, the data were obtained by means of:
  • a review of existing studies - to establish the context and identify gaps in the literature.
  • interviews - to obtain the views of:
    • 26 managers and front-line staff in ex-Service and specific and "mainstream" services who had experienced working with homeless ex-Service personnel, and
    • 3 representatives from central Government departments and national homelessness bodies.
  • qualitative interviews - to obtain:
    • an in-depth understanding of the experiences of 59 ex-Service personnel (32 of whom were homeless at the time of interview and 26 who had recently experienced homeless prior to being rehoused), and
    • a longitudinal perspective by following up the 32 currently homeless cohort over a one year period to evaluate the support of service use and experience pertaining thereto.
• The key findings to derive from the London-based study were as follows.
  • An estimated 6% of London's current non-statutory ("single") homeless population had served in the UK Armed Forces. In comparison with figures reported in the mid 1990s, this represented a substantial decrease of approximately 25%.
  • Whilst this decrease would suggest that the current service network has resulted in positive outcomes, the estimated figures of 1,100 single homeless ex-Service and 2,500 ex-Service personnel in statutorily homeless families would suggest that homelessness among this population should remain a cause for concern.
  • In comparison with the socio-demographic profile of the wider non-statutory homeless population, homeless ex-Service personnel were predominantly male from a white ethnic background and of an older age. In terms of other characteristics and experiences, however, there were more similarities than differences between the wider non-statutory homeless population and homeless ex-Service personnel. It would therefore appear to be the extent of the problems experienced which is the main differentiating factor. However, in comparing the findings from Dandeker et al (2005) with that of Johnsen et al (2008) there is a lack of consensus about the key differences between homeless civilians and homeless ex-Service personnel.
  • In the CHP study, only a small minority reported vulnerabilities and support needs that were unique to those who have served in the military. Thus, despite the myth fuelled by the media, few were found to have combat-related PTSD although some of the interviewees attributed their mental health problems to Service-related experiences mainly relating to active Service.
  • The majority attributed their mental health problems to either trauma encountered pre-Service (particularly in childhood) and/ or post-Service such as bereavement.
  • On the basis of the qualitative findings derived from the CHP study, Johnsen et al (2008) identified four main "life history trajectories", which they regarded as being "broadly indicative" of the pathways into homelessness experienced by ex-Service personnel. These four pathways have been graphically portrayed in Figure 1. Both of the groups who encountered post-adjustment problems reported having had a successful military career in the UK Armed Forces; a finding that tallies with that of Dandeker et al (2005).

Pre-Service vulnerabilities In-Service difficulties Post-adjustment problems

Figure 1: Life History Trajectories of Interviewees

• Although a number of the catalysing factors for homelessness encountered by the ex-Service personnel who participated in the CHP study were not found to be dissimilar to those reported by other homeless populations, the findings did suggest that a combination of military-related factors make ex-Service personnel more likely to experience sustained or repeat episodes of homelessness. These factors have been identified as follows.
  • The rigours of military life equipped ex-Service personnel with coping mechanisms to combat the hardships of homelessness.
  • The military characteristics of pride and stoicism elevate the perceived sense of "shame" about being homeless resulted in a reluctance to seek or accept help.
• Despite the recent expansion of priority need categories in homelessness legislation (as summarised in Section 3), in the main ex-Service personnel were not accepted as statutorily homeless by Local Authorities. As is the case with other non-statutory homeless men, they were invariably regarded as "low priority" in social housing allocations.
• Seven key recommendations emerged from this study, six of which pertained to identifying ways to enhance the provision of services as a means of preventing homelessness among ex-Service personnel. These were:
  • identifying ways to break down the "shame" barrier;
  • raising awareness of available services;
  • streamlining service access;
  • increasing the availability of settled accommodation;
  • formalising tenancy sustainment services (particularly in respect of those re-housed into independent social housing), and
  • combating social isolation (a measure which could help those with substance misuse problems).
• From a research perspective, Johnsen et al (2008) endorsed the need for more commissioned research targeted at homelessness among ex-Service personnel elsewhere in the UK to identify the: (i) extent of the problem, and (ii) adequacy of service provision. They also emphasised the need to ensure that any subsequent action undertaken to address identified gaps in service provision should be preceded by engagement with all the agencies involved to justify the: (i) development of services dedicated specifically for ex-Service personnel, and/ or (ii) expansion of existing mainstream provision.

5.3.5 Employment

Harley et al (2009)

• In June 2008, Poppyscotland commissioned Blake Stevenson (in association with ESOTEC) to undertake a research study into the employment needs of disabled and vulnerable Veterans in Scotland. The purpose of the survey of Veterans in Scotland was to: (i) obtain their views on and experiences of barriers that ex-Service personnel may encounter when attempting to access employment, and (ii) identify how best these barriers may be overcome. The mechanism for distribution of approximately 900 paper copies of the questionnaire was by means of 12 organisations. In addition, electronic access to the survey was available through the unofficial army, navy, and airforces websites and the websites for Poppyscotland and Veterans Scotland. An advertisement was also placed in the Royal British Legion Scotland newsletter. The limitation of using such an approach as a sampling frame to obtain a representative sample is that it is not possible to gauge the total size of the target population. By the same token, although 389 completed surveys were received (of which 207 were Scottish Veterans), it is also not possible to establish what proportion that figure represents as evidenced by the fact that no response rate was reported. Moreover, as this questionnaire was made available on the worldwide web, there is no guarantee that all those who responded were genuine Veterans. However, the inclusion of six focus groups comprising Veterans (although it is not specified how many there were) would enable a validity check in order to ascertain to some extent whether or not that which was reported in the surveys differed considerably in terms of the issues identified.
• Notwithstanding these methodological limitations, the survey findings highlights some of the key issues affecting Veterans in Scotland with regards to access to employment and the labour market barriers that mitigate the potential for securing civilian employment. Key findings were as follows.
  • Of the 383 individuals who completed the Veteran Survey, 207 (54%) lived in Scotland, with the majority residing in the City of Edinburgh (15.5%). Fife (9.7%), West Lothian (6.8%), Perth & Kinross (6.3%) and Glasgow City (6.3%) were the other areas which had the highest number of respondents across the 32 areas identified.
  • In terms of the whole sample, the majority (75%) had served in the British Army and 30% had served an average of more than 20 years. Only 4% had served for less than three years. Whilst in Service 41% had sustained an injury or illness that subsequently restricted their job opportunities.
  • Over half the sample had left the UK Armed Forces more than 10 years previously. Of the majority (70%) who were employed at the time of completing the survey, 90% worked fulltime and were in a permanent job (93%). On leaving the Service, it took less than 3 months for 58% to find a job. However, a range of problems were experienced by a number since leaving the Service which respondents perceived as making it more difficult to find or keep a job, as shown in Table 14.

Table 14. Issues Affecting Employment

Type of Problem	Percentage of respondents who experienced a problem(s) %	Took one year or longer to find a job %	Suffered an injury or illness %
Family or relationship problems	42	50	63
Lack of relevant training or skills	40	48	58
Financial problems	40	62	65
Social isolation	35	55	60
Mental health difficulties	34	53	58
Problems with anger management	34	52	54
Problems with drug or alcohol misuse	21	25	38
Homelessness	14	25	27
A criminal record	11	18	19

• The report also provides a comprehensive overview of the policy context for improving access to employment for ex-Service personnel and a thorough evaluation of the current status of service provision to ascertain the extent to which the employment needs of disabled and vulnerable Veterans are being met in Scotland.
• Of particular value given the purpose of our scoping review, was the finding that there is a paucity of comprehensive data available to enable the accurate identification of unemployment levels and "economic inactivity" amongst Veterans in Scotland (as well as in the UK).
• In accordance with previous studies, the findings reported by Hurley and colleagues showed that the majority of Veterans made a successful transition from military to civilian life in terms of securing employment. However, for those individuals adversely affected by different types of problems, gaining and sustaining employment in "civvy" street presented a major challenge.
• The outcome of the review of current service provision confirmed that Scotland has a host of employment services available to Service leavers and Veterans including the CTP resettlement packages (described in Section 3). However, a number of gaps were identified particularly in terms of meeting the needs of disabled and vulnerable Veterans.

5.3.6 Criminal Justice System

NAPO (2008, 2009)

• In 2008, NAPO published a briefing which included findings from a survey conducted by Veterans in Prison on 10 UK prisons. Based on self report data, the figures were extrapolated to estimate that 9.1% of the UK prison population had served in the military; a figure that equated to 8,500 individuals.
• In 2009, NAPO undertook a further survey of probationer staff. By means of the same extrapolation techniques, it was reported that the Probation Service in England and Wales was responsible for the supervision of an estimated 12,000 Veterans who were either on community sentences or parole (i.e., 6% of all those under supervision).
• The estimates from both surveys, however, need to be interpreted with caution on the grounds that they were based on small samples, failed to confirm Veteran status, and did not account for geographical variations.

5.4 academic-based research reported in the peer review literature

5.4.1 Methods and Caveats

• In view of time and budgetary constraints, it was not possible to conduct a systematic literature review. The main purpose of the search strategy therefore was to identify key papers and systematic reviews informed by themes identified during the course of the six week consultation process.
• To source this literature involved accessing the peer-review medical and social science literature electronic databases principally using PubMed, Medline, Psychlit, and EMBASE.
• Although the main focus of the search was on the UK literature published predominantly over the past decade, key references were also sought from the Australian, Canadian, American and European literature.
• In accordance with the holistic approach described in Section 1, the themes incorporated within this search cover a broad spectrum.

5.4.2 Pre-Service Factors

5.4.2.1 Childhood adversity

• Early studies (e.g., Engel et al, 1993) suggested that a history of childhood adversity may increase the risk of developing combat-related PTSD. Bremner et al (1993) found that Vietnam Veterans with combat-related PTSD reported higher rates of childhood physical abuse than Veterans without PTSD (26% versus 7% respectively) after controlling for the extent of combat exposure.
• Within a military context, Iversen et al (2007) sought to investigate the association between childhood adversity (based on self-reported childhood vulnerability) and subsequent health outcomes (including general psychopathology, alcohol misuse and previous self harm). The sample derived from the first phase of the KCMHR cohort study and comprised Service personnel who were in service at the time of the Iraq war in March 2003. The analysis was restricted to males only because of the relatively small number of women in the military and, therefore, in the sample as a whole. In addition, Reserve personnel were excluded from the analysis due to the KCMHR evidence of an interactive effect between their unique military status and operational deployment (Hotopf et al, 2006; Browne et al, 2007). Of particular note was the evidence that a higher number of vulnerability factors reported in childhood (i.e., "pre-enlistment vulnerability") were positively associated with individuals who were single, of lower rank, with lower educational status, and serving in the Army, and a range of adverse health outcomes. The two key pathological predictors were factors relating to "family relationships" and "externalising behaviours" thereby reflecting the home environment and behavioural disturbance respectively (Iversen et al, 2007). However, the extent to which the prevalence of these factors as predictors of pathology in a military population compares to that of a similar age-matched general population cannot be addressed by this study. To do so requires the linking of the KCMHR cohort with a concurrent general population cohort that has been assessed on comparative vulnerability and health outcomes.
• The association between childhood adversity and PTSD reported in the Iversen et al (2007, 2008) studies however does concur with the findings of the robust meta-analyses undertaken by Brewin et al (2000) and Ozer et al (2003). Similar findings have also been reported in the US military population (e.g., Cabrera et al, 2007). Various explanations for this association have been proffered including genetic (e.g., Koenen et al, 2003) and psychosocial (e.g., Koenen et al, 2007) factors. King et al (2006) suggested that childhood adversity may increase the likelihood of individuals developing PTSD by means of a "double hit". In other words, they are not only predisposed to getting PTSD following exposure to a traumatic event but they are also more likely to encounter trauma in a combat-related situation. However, findings of a study conducted by Stein et al (2005), which explored the effects of childhood, lifetime trauma, combat exposure and coping on PTSD symptoms among a sample of Gulf War Veterans, found that for individuals with a low combat exposure, more severe childhood trauma was related to greater PTSD severity. Conversely, a greater severity of childhood trauma was associated with lower PTSD severity in individuals with high combat exposure. The authors suggested that individuals who experience early childhood adversity may develop coping skills that help them deal with subsequent traumatic experiences such as combat.
• Owens et al (2009) investigated the effects of combat exposure, childhood trauma and depression on the severity of PTSD in 299 male Veterans from the Korean War, World War II, Vietnam, and the first Gulf War who were screened on admission to a PTSD unit. Results of a multiple regression analysis showed that combat exposure and depression were significant predictors of PTSD severity. The relationship of early childhood adversity and PTSD severity however was found to be more complex, but supported the earlier findings of Stein et al (2005). The extent to which these findings would generalise to women and to non treatment-seeking populations has yet to be established.
• Whilst the relationship between PTSD and other factors are complex and interactive, the evidence from the meta-analyses undertaken by Brewin et al, (2000) and Ozer et al (2003) suggests however that pre-trauma factors have a weaker association with PTSD than do peri-traumatic or post-traumatic factors. Post-traumatic factors are the most potent of all three categories. This has important implications (principally because we do most about what happens after a trauma).

5.4.2.2 Socio-economic adversity

• In civilian studies following traumatic experiences, socioeconomically disadvantaged populations have been found to be at greater risk for psychiatric and somatic disorders (Neeleman et al, 2001). Those in the lowest social and economic strata have two to three times the risk of psychiatric disorders, in particular with regards to depression and anxiety disorders. Similar relationships are apparent in military populations. Low income and lack of education are associated with chronic stress-related disorders (e.g., anxiety disorders, major depression, and substance- use disorders). In some studies, low military rank was also associated with a greater risk of a stress-related disorder (e.g., Fiedler et al, 2006); a finding which may in part reflect the fact that higher ranking Service personnel are not engaged directly in combat. Ikin et al (2004) however found that, although Australian Gulf War deployed Veterans were at higher risk for developing any anxiety disorder post-combat than were non deployed Veterans, the risk did not vary significantly by rank, whether officer or enlisted.

5.4.2.3 Psychiatric history

• Black et al (2004) in a study of Gulf War Veterans found that the greatest risk of developing an anxiety disorder post-combat was the presence of a pre-existing anxiety disorder (of any type) and a pre-existing depressive disorder. A previous history of any psychiatric disorder increased the overall risk of developing an anxiety disorder post-combat was increased by a factor of four.
• A study by Ikin et al (2004) found that similar percentages of Australian Gulf War deployed Veterans (31%) and a comparison group of non-deployed (Era) Veterans (34%) reported having had a psychiatric disorder prior to deployment, the most frequent disorders of which were substance use and anxiety.
• Prior to their deployment in Iraq in 2003, Hoge et al (2004) screened 2,530 US Infantry soldiers for mental health disorders. A total of 14.3% of the sample reported having suffered from a moderate or severe mental health problem before deployment. In terms of specific problems, these were: depression (5.3%); anxiety (6.4%); alcohol misuse (17.3%), and PTSD (5.0 %).
• These findings highlight that a substantial proportion of military personnel may be deployed on operations at increased risk of a mental health disorder on the basis of their psychiatric history alone. However, the extent to which these figures would be sustained across all three Services is questionable.

5.4.2.4 Personality

• Studies of Vietnam and Gulf War Veterans suggest that particular personality or psychological characteristics can affect an individual's response to deployment-related stress. For example hardiness has been found to be protective against the adverse effects of combat stress and stressful life events as well as being a significant predictor of health outcomes (Bartone, 1999). Dolan & Adler (2006) surveyed US Army soldiers pre- and post- a six month peacekeeping mission in Kosovo. "Military hardiness" (i.e., the degree to which individuals felt committed to and had a sense of control over their work experiences) was found to be correlated with psychological but not physical health during and after deployment. Among those soldiers who experienced high levels of deployment stressors, those with greater levels of hardiness suffered less from depression post-deployment.

5.4.2.5 Coping style

• In addition to positive coping style (e.g., Wolfe et al, 1993), a perception that some benefit derives from military experience is associated with a reduced potential for adverse health effects after combat exposure. Findings reported by Jennings et al (2006) on Veterans in the "Normative Aging Study" (mean age of 74 years) who had a favourable appraisal of their combat experience, perceived benefits of military experience, and had positive coping strategies, suggested that these may mitigate against long term adverse health consequences.

5.4.3 In-Service Factors

5.4.3.1 Changing nature of combat

• There is no single "experience" of war (Wessely, 2005). Combat zones vary, as do weaponry, strategies and tactics, and the motives for the aggressive encounter. These and related factors need to be identified and considered to advance knowledge and understanding of the differences and similarities of reactions displayed by combat troops (Alexander & Klein, 2009). Almost every military era generates some technological innovation which transforms the conduct and effectiveness of combatants. Contemporary weapons, however, are not only more devastating in their destructive power but they are much more mobile and flexible in their use. Another important issue is that modern warfare has moved from "linear"^[170] to "swirling"^[171] tactics (Gabriel, 1987, p.19).
• In this new combative environment troops may find themselves deep in the heart of enemy territory and isolated from their main supporting force. Strike aircraft (fixed wing and helicopters) through their weaponry, speed and mobility have re-designated what are the "safe" rear zones. Modern communications and optical technology have ensured that military combat can now be engaged 24 hours a day; in poor weather and night conditions, and in the most inhospitable terrains. As a consequence, there is little respite for combat troops, particularly from anticipatory anxiety. The range and accuracy of contemporary weapons have transformed the "killing zone". In World War I this was measured somewhere between five and 10 miles; now, it has to be measured in hundreds of miles. A number of these technological and related changes in combat present themselves most recently in the theatres of Iraq and Afghanistan.
• Furthermore, with advances in body armour and battlefield medicine, catastrophic combat injuries that would not have been survived in previous conflict can be effectively treated, as evidenced by the outcome of the recent Healthcare Commission Review of the Defence Medical Services (2008) and the National Audit Office (NAO) report on treating injury and illness arising on military operations (NAO, 2010). Moreover, both of these reviews confirm that there has been a steady increase in Service-related illness and injury rates. For example, the NAO found that, in comparison with the data for 2001 (when rates of the level of injury and illness sustained on Operation HERRICK were at zero), in 2009 a total of 131 Service personnel had suffered serious injuries on deployment. As the figures for Operation HERRICK have increased over time, the figures pertaining to Operation TELIC have gradually decreased from the highest rate of 46 in 2003 to the lowest rate of 1 in 2009. Both sets of figures however are likely to be an underestimate given that the data for 2009 based on recorded medical attendances on military operations were only available up to 31 October 2009. Relative to the number of serious injuries sustained on Operation HERRICK and Operation TELIC, a considerably higher rate was reported for the total level of minor injury and illness. In 2009, the combined rate for both operations suggested that the health of 31,687 Service personnel had been compromised to some extent, although this was less than that reported in 2007 (n=38,419) and 2008 (n=47,035).
• As has been the case with the increase in the level of serious physical injury, the numbers of Service personnel with mental health conditions have also increased since 2006 from 45 to 380 in 2009 for those deployed on Operation HERRICK. However, although the 2009 level (n=199) is higher than that of the 2006 level (n=74), there has been a decrease when compared with the previous two years of 2007 and 2008 (n=298 and n=239 respectively).
• Women's roles in the contemporary conflicts of Iraq and Afghanistan have expanded well beyond their roles in previous conflicts, both in terms of the number of women involved and the nature of their involvement. In 2010, the total percentage of women in the UK Armed Forces was 9.1% (N=17,900). Whilst it remains the case that female military personnel are excluded from any specialisation where "…the primary duty is to close with or kill the enemy", this does not protect a number of them from exposure to combat situations given a war with no front line, in which they serve in a variety of support positions that involve leaving military bases with a substantial risk of coming under direct fire (Hoge et al, 2007).
• Analysis of data from a random sample of UK Armed Forces deployed to Iraq revealed that 16% of women had come under small arms fire, 40% had come under mortar/artillery fire, and 37% had witnessed serious injury to personnel (Rona et al, 2007). However, the extent to which robust conclusions can be drawn regarding the differential effects of combat exposure on male and female military personnel is severely restricted. Previous research on the effects of combat exposure on mental health has either focussed exclusively men or the sample has contained only a small subset of women as confirmed by a recent review conducted by Street et al (2009) on stressors faced by female service personnel deployed to Iraq and Afghanistan. The authors concluded that additional research is required on gender differences in combat exposure and its impact on mental health post-deployment. Such research should include the additive effects of other trauma-related experiences on combat exposure (e.g., sexual assault) and other interpersonal stressors (e.g., lack of perceived support from comrades) as well as the role of pre-military and post-military interpersonal trauma. In terms of differential effects of training and military service on physical health, analysis of medical discharge data by Geary et al (2002) support previous reports that female personnel in the UK Armed Forces are significantly more likely than their male counterparts to be medically discharged from the UK Armed Forces due to physical injuries and musculoskeletal problems.

5.4.3.2 Changing nature of operational deployment

• The high operational tempo of Iraq and Afghanistan has led to a significant acceleration in typical deployment rotations. The length of deployment, once relatively predictable, has now become uncertain in the face of frequent deployment extensions, as well as the heightened likelihood of multiple deployments in a relatively short period of time. This change in the nature of operational deployment has raised concerns about the possible adverse effects on the mental health of military personnel. To address these concerns, Fear et al (2010) investigated the psychological impact of deployment to Iraq and Afghanistan of UK Armed Forces personnel from 2003 to 2009, the effect of multiple deployments, and time since return from deployment. A total of 9,990 participants from three randomly selected samples completed the study questionnaire, of whom 83% were Regulars and the remainder were Reservists. The number of deployments was not found to be significantly associated with any of the three outcomes under study (i.e., probable PTSD, common mental disorders, and alcohol misuse). Furthermore, the overall prevalence of mental disorders had not significantly changed between 2003 and 2009. A modest effect of deployment to Iraq and Afghanistan was observed for Regulars in respect of increased alcohol consumption. In addition, those Regulars who were deployed in combat roles also reported a small increase in probable PTSD with time since return from deployment. Despite variation in the intensity of combat over different deployment periods in both Iraq and Afghanistan (and consequently the number of casualties sustained), no fluctuations in the reporting of probable PTSD was observed. However, the injurious effect of more recent deployment in Afghanistan has yet to be evaluated thereby highlighting the importance of continued surveillance and monitoring of mental health outcomes for deployed UK military personnel. This is particularly the case for deployed reservists who, despite various endeavours to improve their mental health pre- and post-deployment, continue to report an increase in PTSD.
• Few studies, however, have evaluated the effects of a "mismatch" between actual and expected duration of deployment on mental health and well-being. However, a recent systematic review of nine studies found that a deployment period of more than six months coupled with an increased likelihood of having these periods unexpectedly extended, can adversely affect the health and well-being of both deployed personnel and their families (Buckman et al, 2010). The adverse effect of long deployments, however, is not just about the risks associated with being in theatre but also the stressors associated with concern for family members and difficulties in maintaining family relationships. Being separated from family was perceived by UK military personnel as one of the least rewarding aspects of deployment in Iraq (Sundin et al, 2010).
• Evidence of higher levels of psychological difficulties in combat and, most strikingly, on demobilisation has been found among UK reservists who have served in Iraq (Browne et al, 2007). Compared with Regular service personnel, reservists reported more problems at home during deployment, more negative homecoming experiences and poorer marital satisfaction. Of note is that adjustment for military factors accounted for the excess of all adverse health outcomes except for PTSD. The PTSD health effect only disappeared when adjustment was made for problems at home. One explanation for the increase in adverse health outcomes is that, for reservists at least, adverse domestic experiences may be exacerbating and prolonging PTSD symptoms (Browne et al, 2007).
• The effect of parental deployment on families and children is of increasing concern as tours lengthen and multiple deployments to combat zones increase. More than a million children and families have experienced the stress of deployment of a family member to either Iraq and/ or Afghanistan (McFarlane, 2009). The effect of combat-related parental separation on family stress requires an understanding of the unique culture of military life and military families. Although many occupations may require extended periods of parental separation, the risk of parental injury or death intensify the stress experienced by military family members, which is often exacerbated by unsuitable media coverage (Pinder et al, 2009).
• In addition, it is important to recognise that deployment comprises a number of different phases (known as the "cycle of deployment") as shown in Table 15, each of which is characterised by a different time frame and specific emotional challenges including the need for emotional detachment, changes in family roles and routines, emotional destabilization and reintegration of the returning parent (Lincoln et al, 2008).
• Reviews of the impact of military deployment on children and family adjustment have predominantly been addressed from a descriptive and clinical perspective. In developing the emergent themes from these reviews, McFarlane (2009) has identified a number of limitations in the current literature including the fact that the research to date has been US-based and has focussed predominantly on traditional two-parent families where the male parent is deployed. Research that takes into consideration military personnel with different family configurations (e.g., dual-deployed parents and single parents) and from other countries is urgently required. Moreover, an increase in the deployment of Reservists in the UK Armed Forces and concerns about poorer health outcomes following deployment highlights the need for a greater understanding of the impact of the additional challenges facing families of Reservists compared to the family members of Regular personnel.

Table 15. "Cycle of Deployment"

Phases	Time
Pre-deployment (notification to departure)	Varies from several weeks to over a year
Deployment (departure to return)	1st month
Sustainment	2-8 months
Re-deployment	last month
Post-deployment	3-6 months

Source: Pincus et al (2005)

5.4.3.3 Social support

• Most studies about social support focus on homecoming support, whether given by family, friends, or the community. Few studies have investigated social support during the period of deployment to a war zone. One notable exception was an early study conducted by Stretch (1985) of Vietnam-theatre and Vietnam-era Veterans. Social support pre- and post-deployment was found to be a key factor in the development of PTSD symptoms with social support accounting for 12% of the explained variance. The lack of studies of the role of social support during deployment is an important gap to be addressed given that military personnel report "being away from the family" as a leading deployment stressor (Rona et al, 2007). It is difficult however to determine whether low social support leads to mental health sequelae or whether psychiatric problems reduce social support, or whether the relationship is indirect with other variables, such as the association of personality with both social support and other psychopathology.

5.4.3.4 Unit cohesion

• The role of unit cohesion has attracted increasing attention in studies of mental health outcomes in military personnel. A positive association between unit cohesion and performance have been reported by several studies and meta-analyses along with support for a relationship between enhanced wellbeing and readiness with higher levels of unit cohesion. The identification of risk factors for PTSD among UK Armed Forces personnel suggested that unit cohesion may also protect against the development of PTSD and combat stress reactions (Iversen et al, 2008). Of concern, however, is that excessive alcohol use is also associated with moderate to high levels of comradeship on operational deployment (Browne et al, 2008).
• A more recent study conducted by Sundin et al (2010) found that the level of unit cohesion did not explain differences found in mental health outcomes and occupational risk among three groups of military personnel (commando, airborne and other army infantry). Although the Royal Marine Commandos and the paratroopers were more likely to report multiple physical symptoms or fatigue compared with other army infantry, the Royal Marine Commandos had significantly lower levels of general mental health problems and lower scores on the Post-traumatic Checklist compared with the other army infantry. As this effect was found to be independent of combat exposure and socio-demographic differences and not due to the theatre of deployment, the researchers proffered differences in level of preparedness as one possible explanation. The high level of preparedness in the Royal Marine Commandos and paratroopers may protect against the adverse impact of combat-related experiences in theatre. However, because the study was limited by data collected as part of UK military cohort study of personnel serving at the time of the 2003 Iraq war, it was not possible to evaluate differences in selection and training among the three groups. Interpretation of the findings is also limited by the cross-sectional nature of the study.

5.4.3.5 Mortality

Suicide-related mortality

• Macfarlane et al (2000) published a post-war mortality study of all 53,462 UK Gulf War Veterans who served in the Gulf at sometime between September 1990 and June 1991. Comparisons were made with an equal number of Veterans who were serving in the UK Armed Forces on 1 January 1991 but who were not deployed to the Gulf. Selection was random but stratified to match the Gulf cohort on age (within a five year span), gender, service, fitness for active service, and rank. Data from the NHS Central Register (Office for National Statistics; ONS) provided information on the date and cause of death recorded on the death certificate or the Defence Analytical Services Agency. For each cause of death a mortality rate was calculated based on the number of deaths and the person-years risk to compare the mortality ratio (MRR) with 95% confidence intervals (CI) between Gulf War Veterans and non-Gulf War Veterans. As was the case with US Gulf War Veterans, mortality from external causes was higher in the UK Gulf War Veteran cohort while mortality from disease-related causes was lower. The higher mortality rate due to external causes was predominantly due to a higher number of road traffic incidents, air/space incidents, deaths associated with submersion, suffocation or foreign bodies. No excess of deaths in the Gulf War Veterans cohort were recorded either as suicide or injury from unknown cause.
• Significant controversy exists as to whether serving personnel are at increased risk for suicide and suicidal behaviors compared with civilians in the general population. Thoresen et al (2003) investigated the suicide mortality in Norwegian former peacekeepers who had been deployed at some time between 1978 and 1995. General population data were used for comparison. Standardized Mortality Ratios (SMRs) were calculated for different suicide methods and certain peacekeeping-related variables. Marital status was available for each year and controlled for by using separate suicide rates for unmarried, married and divorced. A moderately, but significantly, increased risk for suicide was found among the former peacekeepers. After adjusting for marital status, that risk was reduced to insignificance. There was however a significant increase in suicide by means of firearms and carbon monoxide poisoning. The increased risk of suicide in former peacekeepers was related to the peacekeepers' lower marriage rate compared to the general population. This finding may indicate that the influence of certain vulnerability factors prior to being deployed resulting in a reduced ability to enter into and remain in stable marital relationship. However, it cannot be excluded that stress reactions following peacekeeping may have contributed to possible strains on interpersonal relationships thereby highlighting the need for psychosocial support for ex-Service personnel and their families.
• Belik et al (2010) suggest that the differences reported in suicide rates in soldiers and their comparability to civilian population rates vary according to the subpopulation being investigated. These authors claim that most studies suggesting higher suicide rates in military personnel compared with the general population are often conducted in Veteran populations (e.g., Kaplan et al, 2007). In contrast, the majority of studies suggesting lower suicide rates are those conducted in active duty forces including Fear et al (2009a) who identified 694 suicide and open verdict deaths among male Regular UK Armed Forces personnel between 1984 and 2007. In comparison with the UK general population, this equated to statistically fewer suicides across all three of the Services. Moreover for each age group (with the exception of Army males under 20 years of age), the number of suicides in each Service was lower than the number expected based on UK general population rates. In respect of those younger male Army Service Personnel, there were 1.5 times more deaths by suicide than anticipated.
• Within the US Army, however, suicide is also the second most common cause of death, with rates varying between 9 and 15 deaths by suicide per 100,000 people (Ritchie et al, 2003). Whilst these figures are similar to death by suicide rates in the US civilian population, the military suicide rate during times of peace has generally been reported as being lower than the civilian rate (Kang & Bullman, 2008). Furthermore, previous studies suggest that military service may be a risk factor for suicidal behavior (Kaplan et al, 2007), and that the most common type of traumatic death suffered during armed forces training was suicide (Scoville et al, 2004). More recently, the rate of suicide among US military personnel and Veterans appears to be rising (Kang & Bullman, 2008). Since the start of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom(OIF), the suicide rate for US military personnel who have seen combat has increased to at least that of the general population (Kang & Bullman, 2008); an increase which suggests that exposure to combat may be an important factor that may cause or at least contribute to subsequent death by suicide (Selby et al, 2010). By the same token, military service appears to have some qualities that lower suicide risk in times of peace, with deaths by suicide during basic training being as low as five deaths for every 100,000 military recruits (Scoville et al, 2004).
• The complexity of the relationship between military service and suicidal behaviour has triggered an increasing interest in identifying risk factors of suicidal ideation in military personnel in order to identify more effective ways treat those who are affected. Thoresen et al (2008) investigated the association between war zone stress exposure during international military operations and later suicidal ideation. A follow-up study of 1172 Norwegian male peacekeepers was conducted seven years, on average, after redeployment. Of a subsample of individuals who were prematurely repatriated 17% reported suicidal ideation compared with an overall 6% of Veterans. After controlling for socio-demographic factors, repatriation status, negative life events, social support, alcohol consumption, and marital and occupational status, suicidal ideation remained significantly associated with the level of exposure to Service-related stress and was mediated by a combination of post-traumatic stress symptoms and general mental health problems.
• More recently, Belik et al (2010) sought to determine whether the prevalence and correlates of past-year suicidal ideation and suicide attempts differ in Canadian soldiers when compared with Canadian civilians. The data derived from the Canadian Community Health Survey Cycle 1.2-Canadian Forces Supplement in conjunction with the 2001-2002 Canadian Community Health Survey Cycle 1.2. Logistic regression interaction models were used to explore differences between correlates of suicidal ideation and suicide attempts comparing Canadian military personnel with civilians in the general population. Although no significant difference was found between these two samples in terms of the prevalence of past-year suicidal ideation, the prevalence of past-year suicide attempts was significantly lower in the Canadian forces sample compared with the civilian population; a finding which is consistent with other studies that have shown that Service personnel are at lower risk of completed suicide than the general population (e.g., Fear et al, 2007). Key correlates of suicidal ideation and suicide attempts that differentially affected Canadian Forces personnel when compared with Canadian civilians included gender and marital status. Women in the Canadian Forces had a higher likelihood of suicide attempts than did women in the civilian population, which may suggest that military women experience a more negative impact of combat exposure compared with men (Tolin & Foa, 2006). Moreover, the prevalence of sexual trauma during deployment (including sexual assault, rape, and sexual harassment) has been reported as being higher among female military personnel than their male counterparts (Street et al, 2007), which may exacerbate the negative mental health consequences of combat exposure (Smith et al, 2008).
• Contrary to earlier studies (e.g., Fear et al, 2007), no significant differences were found between members of the Canadian Forces and the civilian population with regards to the association between age and suicidal behavior. There were however higher rates of suicidal ideation and suicide attempts among individuals in the younger age groups in both populations. Canadian Forces personnel with depression were found to be more likely to attempt suicide than depressed individuals in the civilian population. Alcohol dependence and high levels of alcohol use among Canadian forces members were less likely to be associated with suicidal ideation than was alcohol misuse in the civilian population. Overall, these findings support the hypothesis that lower suicide rates among military personnel may be a result of the "healthy soldier effect". At the point of enlistment, Service personnel are generally physically and mentally healthier than the general civilian population, due to the selection procedures for military service combined with requirements to maintain that standard of well-being (McLaughlin et al, 2008).

Injury-related mortality

• Whilst the focus of many studies of post-conflict mortality has varied and their findings are commonly equivocal, one relatively consistent finding pertains injury-related mortality. Knapik et al (2009) undertook a systematic literature review of post-deployment injury-related mortalilty among military personnel deployed to conflict zones. A total of 20 studies were eligible for inclusion, and all involved Veterans serving during either Vietnam or the Persian Gulf War. Meta-analysis was conducted to compare injury-related mortality of military Veterans who had served in these conflict zones with that of contemporary Veterans who had not. Key findings to emerge from that analysis was that in the deployed Veterans:
  • injury-related mortality was elevated for Veterans serving in Vietnam during 9 to 18 years of follow-up;
  • a substantial excess of mortality was associated with road traffic incidents;
  • excess mortality decreased over time.

It was hypothesised that the excess mortality in Veterans deployed to conflict zones was due to a number of factors including PTSD, coping behaviours (e.g., misuse of substances), ill defined symptoms and diseases, risk taking behaviours, and a lower level of survivability due to the nature of injuries sustained in conflict zones.

5.4.4 Physical Health

5.4.4.1 Cancer

• There has been concern about a possible link between service in the Gulf and an increased risk of cancer, particularly among those who are exposed to depleted uranium, oil well fire smoke and other petrochemical products. McCauley et al (2002) investigated rates of cancer in US Gulf War Veterans residing in five US states in 1999. This investigation formed part of a larger study to evaluate neurologic and neurophysiologic signs and symptoms in 653 Veterans who may have been exposed to chemical-warfare agents due to the destruction of munitions at Khamisiyah, Iraq. The control group comprised 516 non-deployed Veterans who served in the military at the time, but who were not deployed to Southwest Asia. The frequency of cancer was 1.2% for the Khamisiyah deployed Veterans and 0.6% for non-deployed Veterans. The study is limited however by the: (i) small sample size, (ii) few reports of cancer, and (iii) incomplete verification of the diagnosis with medical records and examination.
• McFarlane et al (2003) assessed all first diagnoses of malignant cancer in a cohort of UK Armed Forces military personnel. The deployed group consisted of all 51,721 military personnel who were deployed to the Persian Gulf during September 1990 to June 1991. The comparison group was made up of 50,755 randomly selected members of the UK Armed Forces who were in service on 1 January 1991 but who were did not serve in the Persian Gulf (the Era cohort). The sample was stratified to match for age, sex, service branch, rank, and level of fitness for active service. Follow-up was from 1 April 1991 until diagnosis of cancer, emigration, death or July 21 2002, whichever was the earlier. Cancers were identified by means of the NHS Central Register. During follow-up, 270 incident cases of cancer were identified among the Gulf War Veterans and 269 cases among the non-deployed group. No evidence was found to support an association of Gulf War service with site-specific cancers. Moreover, a review of mortality studies of Australia, US and UK Veterans however has found no significant increase in the risk of death from cancer (Gray & Kang, 2006).
• Testicular cancer: Some evidence of an association of testicular cancer with Gulf War deployment was found in a pilot cancer-registry-based study. Levine et al (2005) matched a stratified sample of 621,902 Gulf War deployed active-duty, Reserve, and National Guard Veterans and 746,248 non-deployed Veterans with the central cancer registries of New Jersey and the District of Columbia. From 1991 to 1999, a total of 17 deployed and 11 non-deployed Veterans were identified with testicular cancer, the greatest proportions of which in the deployed men aged 25 to 34 years and in non-deployed men aged 30 to 39 years.
• Skin cancer: The risk of skin cancer in Australian Gulf War Veterans was investigated by Kelsall et al, (2004). The entire Australian cohort of 1,871 Veterans who were deployed to South East Asia was compared with a sample of non-deployed Veterans matched for service type, sex and age. Participants completed a self-report questionnaire about medical conditions that had been diagnosed or treated by a medical doctor and about when those conditions had been diagnosed. A comprehensive health assessment was also conducted by a specially trained health professional who was blind to the deployment status of the participants. No increase in the prevalence of probable or possible skin cancers diagnosed after 1991 was found in the Australian Gulf War Veterans when compared with their non-deployed counterparts.
• PTSD and cancer: Few studies have assessed cancer in Vietnam War and Gulf War Veterans who have been diagnosed with PTSD. Boscarino (2005) examined the excess post-service mortality from cancer in Vietnam Veterans who were known to be alive in 1983 and who completed a telephone interview at that time on PTSD symptoms and health status. The telephone interview was administered to 7,294 Vietnam-theatre Veterans and 7,364 Vietnam-era Veterans. A total of 377 Veterans were diagnosed with lifetime PTSD according to the Diagnostic Interview Schedule Version III (DIS-III). Boscarino found an increase in the risk of death from cancer in Vietnam-theatre Veterans with PTSD.

5.4.4.2 Diabetes

• Eisen et al (2005) conducted a cross-sectional prevalence study that investigated diabetes among US Gulf War Veterans. In 2001, 1,061 Gulf War deployed Veterans and 1,128 non-deployed Veterans underwent physical examinations at 16 VA medical centres. As part of the "National Health Survey of Gulf War Era Veterans and Their Families", the study participants were randomly selected from among the 11,441 deployed and the 9,476 non-deployed Veterans who had participated in the 1995 phase of the study by completing a postal self-report questionnaire or telephone administered questionnaire about their health. Diabetes mellitus was found in 4.2% of the deployed and 3.5% of the non-deployed Veterans, but this difference was not a statistically significant one.

5.4.4.3 Thyroid disease

• In the Eisen et al (2005) study, thyroid function was also assessed in the Gulf War deployed and non-deployed Veterans. Of the deployed Gulf War Veterans, 1.6% had hypothyroidism compared with 1.2% of the non-deployed Veterans. No significant increase in the risk of hypothyroidism was found in deployed Gulf War Veterans.

5.4.4.4 PTSD and endocrine diseases

• Schnurr et al (2000) found no significant association between combat-related PTSD and physician-diagnosed medical conditions in 605 combat Veterans of World War II and the Korean War. Only six were found to be positive for PTSD (as measured by the Mississippi Scale for Combat-Related PTSD). Endocrine disease was evident in 93 (15%) of the Veterans on medical examination.
• Spiro et al (2006) assessed the prevalence of PTSD, depression, and several medical conditions in a sample of 2,425 male ambulatory-care patients at a VA medical facility as part of the Veterans Health Study. The screening criteria for PTSD were met by 20.2% of patients. When compared with those who did not meet the criteria for PTSD or depression, no significant increase in the risk of Type 2 diabetes or thyroid disease was found.

5.4.4.5 Obesity

• Exposure to stressors may affect eating behaviour and theoretically predispose to obesity or eating problems. Jacobsen et al (2009) analysed longitudinal data from the Millennium Cohort Study on participants who completed baseline (2001-2003) and follow-up (2004-2006) questionnaires (n=48,378) to investigate new-onset disordered eating and weight changes in a large military cohort. Multivariable logistic regression was used to compare these outcomes among those who: (i) deployed and reported combat exposures, (ii) deployed but did not report combat exposures, and (iii) did not deploy to Iraq and Afghanistan. After adjustment for baseline demographics, military, and behavioural characteristics, no significant association was found between deployment and new-onset disordered eating in women or men. A subgroup comparison analysis of deployers revealed however that deployed women reporting combat exposures were 1.8 times more likely to report new-onset disordered eating and 2.4 times more likely to lose 10% or more of their body weight compared with women who deployed but who did not report combat exposures. Although no significant overall association was found between deployment and disordered eating and weight changes, the evidence from this analysis suggests that deployed women reporting combat exposures represent a subgroup at higher risk for developing eating problems and weight loss.

5.4.4.6 Arthritis

• Dominick et al (2006) undertook a study to compare the prevalence of arthritis symptoms between: (i) Veterans of the US Armed Forces and non-Veterans, and (ii) Veterans who were users of the US Department of Veterans Affairs (VA) healthcare and Veterans who were nonusers. Participants comprised 123,395 respondents from 36 States in the US who completed the 2000 Behavioral Risk Factor Surveillance System arthritis module. The data analysis was based on self-reports of doctor-diagnosed arthritis, chronic joint symptoms, and activity limitation according to Veteran status. The relationships of demographic characteristics to arthritis were also compared according to Veteran status. Compared with non-Veterans, US Veterans were more likely to report doctor-diagnosed arthritis and VA healthcare users were more likely to report doctor-diagnosed arthritis than Veteran nonusers. Among respondents with arthritis, Veterans were more likely to report chronic joint symptoms and activity limitation than non-Veterans, and VA healthcare users were more likely to report chronic symptoms and activity limitation than Veteran nonusers. Demographic predictors of arthritis diagnosed by a doctor were similar among the three groups. The authors conclude that their findings highlight a need for the increasing prevention of orthopedic injuries in the military (e.g., by means of self management interventions) as a potential way of reducing the risk of arthritis in military personnel.

5.4.4.7 Reproductive health

• Birth defects: Araneta et al (2003) conducted a study investigating birth defects in the offspring of Gulf War Veterans by examining hospital records of births in 1989 to 1993 to military personnel in the USA. These records were subsequently linked to data from State and county birth-defects surveillance programmes to identify infants born to military personnel who served in the Gulf War. During this time period, a total of 11,961 infants were born to those Veterans who served in the Gulf War (including 450 female Veterans) compared with 33,052 infants born to Gulf War era Veterans (including 3,966 females). In infants conceived before and during the Gulf War, there was no significant difference in birth defects between these two groups of Veterans. In infants conceived after the war, the rate of hypospadias was significantly higher in infants born to Gulf War male Veterans than to era male Veterans as was the prevalence of aortic valve stenosis. However, Ryan et al (2004) have suggested that there may be a significant limitation to the interpretation of these findings by virtue of the fact that comparisons were made for 26 birth-defect categories without correction for multiple comparisons. Consequently, there is the possibility that the statistical significance of the observations observed is due to chance.
• Infertility: Maconochie et al (2004) examined infertility based on self report from UK Gulf War Veterans in respect of inability to achieve conception (Type I infertility) and to achieve a live birth (Type II infertility). Male Gulf War Veterans reported significantly higher levels of infertility compared with non-deployed Veterans. Among those males not reporting infertility, time to conception was shorter among non deployed fathers than among Gulf War fathers. Limitations of this study include low response rates which may have increased the possibility of response and recall bias. Kelsall et al (2007) provided self-report data on the fertility of male Australian Veterans of the Gulf War. Compared with non-deployed Veterans the deployed Veterans reported more fertility difficulties after the war although they were more successful at subsequently fathering children. Both groups reported similar rates of pregnancies and live births.
• Sexual dysfunction: Ishoy et al (2001) conducted a clinical examination of 661 Danish peacekeepers who served in the Gulf in 1990 to 1997 and 215 Danish military personnel who were not deployed to the Gulf. By means of a health interview (which included questions about sexual health), participants were asked whether they had experienced any sexual problems (decreased libido or nonorganic erectile dysfunction) that they attributed to service in the Gulf. Self-reported sexual problems were higher among Gulf War Veterans than among controls. A clinical evaluation for serum concentrations of reproductive hormones found no significant differences between the deployed and non-deployed Veterans. Deployed Veterans however were more likely to report sexual problems if they had seen people killed or wounded, witnessed a friend or colleague being threatened or shot, or been personally threatened than if they had not experienced these traumatic events. Compared with Veterans without sexual dysfunction, deployed Veterans with sexual dysfunction also reported more perceived psychological stress during deployment. Simmons et al (2004) used a postal questionnaire survey to collect self-report data on sexual dysfunction in UK Gulf War Veterans. Of the 42,818 male Veterans who responded, 24,379 had been deployed and 18,439 had not. Sexual dysfunction was reported by 0.8% and 0.2.% of the deployed and non-deployed Veterans respectively.
• PTSD and reproductive effects: Cosgrove et al (2002) examined the association between PTSD and sexual dysfunction in 44 US combat Veterans who were undergoing treatment for PTSD at a VA clinic and 46 age-matched combat Veterans without PTSD. Eighty five per cent of Veterans with PTSD had erectile dysfunction compared with 22% of Veterans without PTSD. Severity of PTSD was associated with severity of erectile dysfunction. However, more than half the PTSD Veterans were using psychotropic medications compared with only 17% of non-PTSD Veterans.
• A review of the literature on the reproductive health of Gulf War Veterans has highlighted the extent to which all of the studies comprising that review had methodological limitations (Doyle et al, 2006). To this end, the interpretation of findings from these studies is problematic. Overall, however, the authors concluded the following.
  • For male Veterans of the first Gulf War there was no evidence of an adverse effect of service on the risk of birth defects or stillbirth in infants conceived post-deployment.
  • There was some evidence of a small increase of risk for miscarriage and infertility associated with military service.
  • In respect of female Veterans, no robust conclusions could be reached due to insufficient data.
  • Future investigations of Veterans' reproductive health require prospective surveillance post-deployment.

5.4.4.8 Chronic Fatigue Syndrome (CFS)

• Unexplained chronic fatigue, experienced by both military and civilian populations, has been the subject of much debate by clinicians and researchers alike, but its aetiology and course remain unclear. Moreover, information on the incidence and prevalence of CFS is contradictory. In the UK, prevalence estimates vary by a factor of eight by virtue of natural variation between populations and artefactual variations (e.g., due to differences in research methods and case definitions and/ or to selection bias). Much of the epidemiological research has used complex clinical research definitions, which are designed primarily to enable identification of homogeneous groups of individuals for participation in clinical trials. Such studies generally have exclusion criteria of varying stringency, and, consequently, tend to underestimate the public-health burden of the disease when used in epidemiological research. Most epidemiological studies have been on a small scale, giving inconclusive results with wide confidence intervals. In some cases, inferences about population proportions have been made on the basis of studies that themselves lack a population base.
• Many Veterans returning from the Gulf War and other wars have reported experiencing chronic fatigue (McCauley et al, 2002). Eisen et al (2005) conducted a cross-sectional prevalence study in 2001 of 12 health measures in 1,061 Gulf War deployed and 1,128 non deployed Veterans. As part of the "National Health Survey of Gulf War Era Veterans and Their Families", all participants had completed a postal or telephone administered questionnaire about their health in 1995 phase of that survey. CFS was diagnosed by clinical examination on the basis of the International Chronic Fatigue Syndrome Study Group case definition (Fakuda et al, 1994) by VA clinicians who were blind to the deployment status of participants. Veterans with psychiatric disorders were excluded from participation. However, given the evidence to suggest that depression underlies CFS, by excluding depressed individuals the prevalence of CFS is likely to be substantially reduced. Of those who self-reported symptoms of CFS, only 3 of the 38 deployed Veterans and only 2 of the 8 non-deployed Veterans met the diagnostic criteria respectively. On this basis, the authors concluded that self-reports of CFS in both groups were unreliable. Clinically diagnosed CFS was more prevalent in deployed Veterans (1.6%) than non-deployed Veterans (0.1%) although the absolute difference was very small. The strengths of this particular study are its large sample size, stratified sampling method, analysis of participation bias, comprehensive examination, and use of computer-based algorithms by researchers who were blind to deployment status. Its main limitation is the relatively low response rate of 53% of the eligible deployed Veterans and 39 % of the eligible non-deployed Veterans.
• Several CFS focused studies have been undertaken on UK military personnel. For example, Reid et al (2001) found that the prevalence of CFS was not statistically different between UK military personnel deployed to the Gulf War and non-deployed troops (2.1 % versus 1.8%), but both groups had a greater prevalence of CFS than did the group deployed to Bosnia (0.7%). This finding concurs with the study conducted by Unwin et al (1999). A more recent study by Ismail et al (2008) using baseline data from the original KCMHR cohort examined the prevalence of CFS and related disorders in UK Veterans of the 1990-1991 Gulf War. The 111 Gulf War Veterans who reported physical disability at baseline were compared with 133 non-Gulf War Veterans who reported similar levels of physical disability. In order to exclude any medical conditions which might explain that physical disability, screening was undertaken, and standardised criteria for CFS, chronic fatigue and fibromyalgia were employed. No significant differences were found between the two groups in terms of clinical markers of medically unexplained conditions. Physically disabled Gulf Veterans however were more likely to be overweight, screen positive for hypertension, and have elevated levels of c-glutamyl transferase. In terms of CFS, compared with the physically disabled non-Gulf Veterans, physically disabled Gulf Veterans were more likely to fulfil the criteria for CFS. On the basis of these findings, Fear et al (2009b) suggest that symptoms of CFS in Gulf War Veterans represent a substantial part of the symptomatic distress reported.

5.4.5 Mental Health

5.4.5.1 Post-Traumatic Stress Disorder (PTSD)

• There have been numerous epidemiological studies of the operational health consequences of deployment on military populations exposed to different conflicts and wars. The majority of these studies have focused on providing estimates of the prevalence of PTSD. In World War I most enemies suffered similar levels of psychiatric casualties. By 1917 about 20% (representing 40,000 troops) of the total number of war pensioners from the British Forces were suffering from psychiatric disability (O'Brien, 1998, p.9). Despite their extensive pre-deployment selection scheme, in the Second World War, admissions to the US military hospitals for psychiatric reasons were twice those of the First World War (Gabriel, 1987, p.117). The Korean War (a largely neglected one by researchers) generated, according to Ikin et al (2007), high levels of psychopathology, evident even 50 years after the conflict. The most extensive survey of post-traumatic psychopathology among Vietnam Vets was the National Vietnam Readjustment Study conducted by Kulka et al (1990). It reported PTSD prevalence of 15.2% and 8.5% of male and female troops respectively. (Although post Vietnam figures have been challenged by Frueh et al [2005] on the basis of the veracity of the reports of personal combat exposure.)
• Contemporary conflicts tend to yield lower figures. For example, Kang et al (2003) found that 12.1% of deployed Gulf War Veterans and 4.3% of non-deployed Veterans met the screening criteria for current PTSD using the PTSD Checklist. The risk of PTSD increased with the severity of stress experienced ranging from 3.3% in activated but non-deployed Reserve personnel ("minimal stress") to 22.6% in Gulf War deployed Veterans who had worn chemical protective gear, heard chemical alarms, been involved in active combat duty, and witnessed death ("maximal stress").
• A systematic review of Veterans of the Persian Gulf War of 1991 compared the prevalence of psychiatric disorders in Gulf War Veterans with a group of Service personnel not deployed to the Gulf War (Stimpson et al, 2003). All were cross-sectional studies, and the samples comprised military personnel from the UK Armed Forces, the Canadian forces, the US forces, and the Danish military. A total of 20 primary studies were eligible for inclusion in that review, and nine were subject to a meta-analysis for dichotomous outcomes for PTSD. Although the heterogeneity among studies was substantial, all reported an increased prevalence in PTSD for Gulf War Veterans when compared with non-deployed Veterans. However, the majority of studies relied on self-report symptoms to assess the prevalence of PTSD, and the earlier studies were less robust in terms of their methods with less representative samples, lower response rates and smaller sample sizes.
• The risk of USA combat troops deployed to Afghanistan developing PTSD three to four months post-deployment was found to be 6.2% for Army troops returning from Afghanistan and 12.9% for Army troops and 12.2% for Marines returning from Iraq (Hoge et al, 2007). The risk of developing PTSD pre-deployment was 5% (Hoge et al, 2004). A year after their return from Iraq, 16.6% of the US Army combat troops fulfilled the screening criteria for PTSD (Hoge et al, 2007). Engelhard et al (2007) reported rates varying from 4% - 21% among Dutch troops returning from Iraq. These figures contrast with findings from studies of UK Veterans of the Iraq War where no significant differences were observed in rates of PTSD between those who deployed to Iraq and those who did not (Hotopf et al, 2006), although a slightly increased rate of PTSD was observed for Reservists and those involved in combat. In general, rates of PTSD have been found to be significantly lower among UK Veterans than US Veterans as evidenced by a review of the literature undertaken by Sundin et al (2010) and the findings of a recent study by Fear et al, 2010, which reported a prevalence rate of 4% of PTSD compared with 19.7% for common mental disorders and 13% for alcohol misuse.
• Recent studies of returning Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) Veterans have raised a number of concerns about the long-term mental health consequences of combat exposure (e.g., Seal et al, 2007). Longitudinal evaluations of the persistence of symptoms however are lacking with a few notable exceptions. In a 10 year follow-up to study, Toomey et al (2007) found that 6.2% of US Gulf War deployed Veterans and 1.1% of non-deployed Veterans met a diagnosis for war-related PTSD. Kang et al (2009) analysed data from the 1995 National Health Survey of Gulf War Era Veterans and their Families; a retrospective cohort study in which the health indicators of a population-based sample of 15,000 troops deployed to the Persian Gulf were compared with those who were not deployed (Kang et al, 2000). The health indicators included chronic medical conditions, PTSD, unexplained multi-symptom illness (MSI), CFS, functional status, and health care utilisation. Symptoms of PTSD were measured by means of the PTSD Checklist (PCL); a self-report measure for assessing PTSD symptom severity and for estimating PTSD caseness when the administration of a structured clinical interview is not possible. Fourteen years after deployment, 1991 US Gulf War Veterans continued to report a higher prevalence of a variety of adverse health outcomes (including PTSD) when compared with the Gulf War Era Veterans. This would suggest that combat-related disorders increase the risk of developing chronic health problems.
• In response to health concerns of military members about deployment and other Service-related exposures, the US Department of Defence (DoD) initiated the largest prospective study ever undertaken in the US military. The Millennium Cohort used a phased enrolment strategy with a view to obtaining the participation of in excess of 100,000 US Service and ex-Service members who will continue to be followed up until the year 2022. Participants will be linked to DoD and VA databases with assessments conducted every three years to obtain objective and self-reported data on exposures and health outcomes (Ryan et al, 2007). The sample was provided by the Defense Manpower Data Center (DMDC) representing approximately 11.3% of the 2.2 million US military personnel (both males and females) who were in service as of 1 October 2000 including those from the Army, Navy, Coast Guard, Air Force, and Marine Corps. Individuals deployed to Southwest Asia, Bosnia and Kosovo during the 1998-2000 time period, US Reserve and National Guard members, and female service members were oversampled to generate sufficient power for statistical inferences over the study period. Enrolment commenced in July 2001 and ended in June 2003 resulting in 77,047 consenting participants (i.e., 35% of the eligible contacted target population). Smith et al (2008) sought to evaluate the new onset and persistence of self reported PTSD symptoms in this large population based military cohort by comparing baseline data with follow-up health outcomes data collected between June 2004 and February 2006 on 50,184 participants. At the time of follow-up in excess of 40% of the cohort were deployed between the start of enrollment in 2001 and completion of follow-up in 2006. Of those, 24% had been deployed for the first time in either Iraq or Afghanistan. Incidence rates of 10 to 13 cases of PTSD per 1000 person years were found in this cohort. New onset of self-reported PTSD symptoms or diagnosis were identified in 7.6-8.7% of those deployed individuals who reported exposure to combat compared with 1.4-2.1% of deployed individuals who did not report exposure to combat and 2.3-3% of non-deployers. No evidence was found for deployment affecting the persistence of symptoms in those with self-reported symptoms of PTSD. After adjustment for baseline characteristics, a three-fold increase in new onset of PTSD (according to both self-report and clinician-based diagnosis) was found among deployed military personnel who reported exposure to combat. Smith et al (2008) conclude that these findings emphasise: (i) the importance of PTSD in this population, and (ii) that deployment itself does not significantly affect the onset of PTSD post-deployment, rather it is the nature of the specific exposure to combat which is the main contributory factor.

5.4.5.2 Comorbidity

• Whilst PTSD commonly adopts centre stage, however, it is a condition that is neither the sole psychopathology to emerge post-trauma nor does it commonly occur in isolation from other comorbid conditions, most notably, anxiety, depression and substance abuse (Klein & Alexander, 2009). A European study conducted by Perkonigg et al (2000) reported that 87.5% of individuals diagnosed with PTSD also met diagnostic criteria for at least one other psychiatric disorder, and 77.5% had two or more additional diagnoses. Four hypotheses have been proposed to explain these high rates of comorbidity associated with PTSD. First, it has been hypothesized that pre-existing disorders constitute a vulnerability to PTSD. Second, other disorders are subsequent complications of PTSD. Third, the disorders co-occur because of shared risk factors. Fourth, considering that none of the psychopathology evident in PTSD is unique to the disorder, it has been suggested that PTSD does not exist as a distinct entity and is merely an atypical presentation of an anxiety or affective disorder "…pathoplastically modified by culture, context and traumatic events" (Deahl, 2003).
• Iversen et al (2009b) sought to evaluate the prevalence of and risk factors associated with common mental disorders and PTSD symptoms in a sample of participants which derived from the existing KCMHR cohort during the main fighting period of the Iraq war and subsequent deployments. Using a standard two phase survey technique stratified by deployment status and engagement type (i.e. Regular or Reserve), a structured telephone interview was administered along with standardised measures of health and PTSD. Comparisons of the prevalence of depression, PTSD symptoms and suicidal ideation in Regular and Reserve personnel of the UK Armed Forces were made with their US counterparts. No significant difference was found between the Regular US and UK military personnel who experienced combat in Iraq. Contrary to previous studies this included the absence of substantial differences in the prevalence of PTSD symptoms. In terms of the UK Service personnel, the most common mental disorders were alcohol abuse (18%) and neurotic disorders (13.5%). Few (4.8%) reported symptoms of PTSD. However as is the case with previous studies, those most at risk of psychiatric injury were the Reserve UK Armed Forces personnel, which extended beyond those who served in the initial fighting period of the Iraq war. This finding endorses the value of ongoing commitments to ensuring enhanced care provision to Reservists.

5.4.5.3 PTSD and physical injury

• Over the past 20 years there has been a particular interest in the interplay between physical and psychological injuries (i.e., to the psychological consequences of physical injury caused by a traumatic event) among survivors of a variety of traumatic events including road traffic incidents, terrorism, criminal assault, and burn injuries (O'Donnell et al, 2003).
• While a few studies have shown that risk for PTSD is associated with severity of injury, other studies have failed to replicate these results in civilian populations. The survivors of injuries in contemporary conflicts however face significant psychological and physical challenges, lengthy rehabilitation and readjustment to family, work, and social activities. Multiple amputations pose a significant challenge for survivors and their families. Traumatic brain injuries (TBI) and tympanic membrane injuries are on the increase due to insurgents using improvised explosive devices (IED). Hotopf et al (2006) estimated a 4% incidence of PTSD among UK troops returning from Iraq; Hoge et al (2004) however described a higher figure of just under 13% for returning troops, and Engelhard et al (2007) reported rates varying from 4% to 21% among Dutch troops returning from Iraq. Higher rates of PTSD were associated with higher levels of direct combat exposure and minor wounds or injury, and rates of PTSD among soldiers returning from war increased over time post-deployment as the majority of soldiers with PTSD or depression at seven months had not met the criteria for either condition one month following injury. These findings highlight the clinical challenges of providing early psychiatric care for combat exposed personnel.
• In one of the few studies which have attempted to identify predictors of PTSD following combat-related injury, Koren et al (2005) directly compared in a matched case-control design, injured and non injured Israeli soldiers who experienced the same combat events to estimate the unique contribution of physical injury over and above that of the trauma itself to the subsequent development of PTSD. Consistent with the outcome of some earlier studies (e.g., Kulka et al, 1990; Michaels et al, 1999), their findings unequivocally indicated that bodily injury is a risk factor - rather than a protective one - for PTSD. Approximately 15 months post-injury, 16.7% of injured soldiers had PTSD compared to 2.5% of non injured soldiers with similar combat experiences. Moreover, the data also suggested that the odds of developing PTSD following traumatic injury are approximately eight times higher than those following injury-free trauma. Interpretation of the validity of these figures requires careful analysis of such factors as the intensity of combat; whether the data were from Reservists or full time troops; whether the data derived from self-report or from structured clinical interviews; whether the psychopathology was genuinely combat-related, and how long after deployment were the surveys conducted. Moreover, objective measures of physical injury are often not related to PTSD outcome. This is a very important finding because it highlights the significance of the patient's subjective appraisals in the development of posttraumatic psychological problems (Malt & Olafsen, 1992; Schynder et al, 2001) High quality surgical and nursing care may also provide opportunities for talking through and facilitating adjustment to trauma.

5.4.5.4 Alcohol misuse

• Historically, the soldier has always been a "chemical warrior" (Alexander & Klein, 2008). Alcohol has played a significant role in the military due to the following four inter-related, and possibly inseparable, influences.
  • A substance-abusing personal history (especially among Scots recruits).
  • The (genuinely) protective factor of psychoactive substances against the emotionally deleterious effects of combat (pain, fear and hyperarousal).
  • The ameliorative (if only temporary) effects of psychoactive substances against intrusive memories, insomnia, hyperarousal, and low mood/ high anxiety.
  • The socially cohesive effect of "drinking buddies".
• Although some earlier research was conducted on alcohol use within the UK Armed Forces (e.g., Micklewright, 1993), many of these studies have been limited by adequate comparison groups and by the inability to control for baseline factors that might influence the association between combat, mental health outcomes, and alcohol misuse.
• In 2007, Fear et al reported on a cross-sectional study undertaken to examine: (i) patterns of drinking in the UK Armed Forces, (ii) the extent to which those patterns of drinking varied by gender and other demographic variables, and (iii) differences in drinking patterns when compared with the general population of Great Britain. Based on the random representative sample of the 8686 Regular UK Armed Forces (7937 men and 749 women) who were in service in March 2003. As part of a self-report questionnaire, the assessment of alcohol use was based on the WHO AUDIT (Alcohol Use Disorders Identification Test, Saunders et al, 1993)^[172]. Key findings which derived from that study showed that the level of "hazardous"^[173] drinking in Service men (67%) and Service women (49%) was higher than for the 38% of men and 16% of women in the general population. This also applied to all ages for both men and women in the UK Armed Forces. For Service personnel, binge drinking was associated with being:
  • younger;
  • single;
  • in the Naval service or the Army;
  • deployed to Iraq;
  • childless;
  • a smoker;
  • deployed in a combat-related role, and
  • the offspring of a parent with a substance use problem (drink or drugs).
• A subsequent paper by Browne et al (2007) reported on statistically significant associations between alcohol use and deployment to OpTELIC using a random representative sample of 3,578 Regular male UK Armed Forces personnel. The rationale for this evaluation derived from the finding by Fear et al (2007), which showed that there was a statistical difference (albeit small) in the patterns of drinking by deployment status. On this basis, Browne et al (2007) sought to undertake a more detailed analysis that focused on the association between "heavy" drinking^[174] and specific deployment-related factors (including in-theatre related experiences, perception of comradeship and leadership and problems encountered at home during and deployment on OpTELIC). Furthermore, it was the first study in the UK to examine the association between comradeship and alcohol use. Heavy drinking was found to be more prevalent in Service personnel who had: (i) been deployed with their parent unit; (ii) experienced medium to high unit comradeship; encountered poor unit leadership, and (iii) suffered problems at home during and post-deployment. However, because the number of women identified as heavy drinkers was relatively small (n=64) in the Fear et al (2007) study, the analyses undertaken by Browne et al (2007) focussed on males only. In line with the findings reported by Fear et al (2007) however heavy drinking was associated with all of the same demographic variables. Although previous USA evidence suggested a significant relationship between exposure to combat and the use of alcohol (Prigerson et al, 2002), this was not evident in the Browne et al (2007) study. However, the findings from a previous KCMHR study did report that the risk of alcohol misuse increased with the time spent on deployments (Rona et al, 2007).
• More recently, examination of consequences of deployment to Iraq and Afghanistan by the third largest epidemiological study of UK Armed Forces personnel showed that the effect of deployment on alcohol misuse continues to be most problematic for those in combat roles. Furthermore, despite adjusting for differences in the higher predominance of young males in the military, the levels of misuse were found to be substantially higher level than those reported in the general population (Fear et al, 2010). The extent to which the recent introduction of new alcohol policies by the UK Armed Forces in each of the three services will be effective in addressing this ongoing concern has yet to be established. However, despite attitudinal differences between the UK Armed Forces and the US military towards alcohol use, studies of the US military report similar problems in respect of the effects of deployment and related experiences on alcohol misuse (e.g., Wilk et al, 2010).
• A limitation of a cross-sectional design research design however is that it not possible to determine the causality of association (Silman & Macfarlane, 2004). Thus, interpretation can be problematic as acknowledged by Browne et al (2007) because the use of alcohol was only assessed at one time point (i.e., after deployment). For this reason, for example, the 18.5% who were classified as "heavy drinkers" would have been classified as such prior to deployment. Evidence from the US Millenium Cohort Study^[175] however found that Reserve and National Guard personnel and younger service members who deploy with reported combat exposures are at an increased risk of new-onset heavy weekly drinking and alcohol problems (Jacobsen et al, 2008).
• In terms of those who leave Service post-deployment, Browne et al (2007) highlight the need for further longitudinal data to determine whether the deployment issues they identified have any longer term implications for alcohol consumption of Veterans of the UK Armed Forces. Furthermore, it is imperative to establish the extent to which predictors of excessive drinking in the Veteran population differ from those in the general population in order to inform service provision and the development of appropriate interventions.

5.4.5.5 "Ripple Effect"

• The concept of the "ripple effect" was originally developed to emphasise the fact that traumatic events can have a radiating effect on others, especially the families of the primary victims. Military personnel returning from Iraq and Afghanistan face psychological challenges that can exert profound effects on families and couples (Erbes et al, 2008). Feelings of detachment, or estrangement from others, restricted affect, irritability, and outbursts of anger, may adversely affect the interpersonal relationships of service members with their spouse/ partners. In dealing with such problems, family members may experience a burden of care and may themselves develop psychological symptoms. Thus, the impact of a traumatic event is not limited to traumatized persons but can also impact on their spouse/ partner of family member; a concept which has been referred to as the "ripple effect" of trauma (Klein & Alexander, 2005) or secondary traumatisation (Figley, 1998).
• There is some evidence to suggest that combat or other military-related traumatic experiences may be particularly detrimental to marriage. Cook and colleagues (2004) reported that 31% of World War II prisoners of war with PTSD reported marital distress compared with 11% of those without PTSD. A major limitation of this research however is the undue emphasis placed on the diagnosis of PTSD to the exclusion of identifying problems associated with other post-traumatic psychopathology such as substance abuse, depression, relationship conflict, and occupational dysfunction that are more common and potentially more troublesome to Service members and their families (Batten & Pollack, 2008).
• In a subsequent investigation of reasons for the excess of ill health in Reservists, Browne et al (2007) included problems at home (readjustment or relationship difficulties) and marital satisfaction. Following deployment, Reservists reported experiencing significantly more major problems and readjustment difficulties than Regulars. Because couple and family relationships may serve as either a vital support or challenging obstacle to recovery from combat-related pathology, including physical injury, research is required to identify factors associated with adjustment and recovery.
• Collins & Kennedy (2008) further extend this particular approach to the case of Service members experiencing multiple and severe injuries requiring treatment in the polytrauma system of care due to the substantial burden which may be placed on family members in fulfilling an unexpected caretaking role. There is a need therefore to adopt a dual focus on the individual needs of the Service member in his or her rehabilitation and on the support and functioning of the caregiving spouse/ partner (Sammons & Batten, 2008). It represents a highly topical issue as it concerns an "invisible healthcare system" which constitutes the core long-term care in the community. Despite increasing recognition by policy makers of the need to consider such effects (e.g., National Service Framework for Mental Health [Department of Health 1999]), relatively few studies have systematically pursued a focus on this important aspect of trauma care, and none has specifically examined this issue with regards to combat-injured personnel despite the likelihood that the welfare of partners or immediate family members will impact on the rehabilitation and adjustment of the injured.
• Death of partners in military combat may pose a particular challenge to their families given the possibility of missing bodies and "ambiguous loss"^[176] (Alexander & Klein, 2012). For the military, "Missing in Action" is a not an uncommon outcome. Modern weaponry is so powerful that bodies can be completely atomised: there is nothing to be retrieved. Indeed, it is for this reason that most countries set up a tomb to "The Unknown Warrior" to at least partially provide some closure for families and colleagues.
• Parkes (1985) identified the lack of a body as a poor prognostic indicator for the bereaved. Without a body, denial and wishful thinking may unhelpfully persist. Alexander (1993) noted that, after the Piper Alpha oil platform disaster, some families (who had no bodies returned) lived with the vain hope that their loved ones had been picked up by some foreign sea vessel and would soon be returned to them. The availability of a body provides the bereaved with an opportunity to say "goodbye", "I am sorry", and "I love you" etc. Relatedly, the physical reality of a body helps to release emotions which otherwise can be "frozen". Also, a body, or even a body part, allows families and colleagues to initiate mourning rituals and practices which, as has been argued above, further facilitate grieving and mourning.
• Whether bereaved relatives should be encouraged to view the body after a traumatic death remains a topic for debate. Findings from a UK qualitative study (Chapple & Ziebland, 2010) based on an analysis of 80 narrative interviews undertaken with respondents of different social economic backgrounds, ethnic groups, and types of traumatic death (including suicide) found that, although decisions about viewing the body varied, there was no regret voiced by those who took the decision to view the body of the deceased. On this basis, the authors concluded that, even after a traumatic death, relatives should have the opportunity to view the body and be given time to decide whether to view the body or not.

5.4.6 Transition-Related Factors

• Each year in the UK, approximately 25,000 men and women leave the Armed Forces (Fletcher, 2007) and return to civilian life for a variety of reasons and in a variety of different circumstances (Iversen et al, 2005a). Although the current average length of military service is about four and a half years there are some Service personnel who leave the Service early having failed to pass their basic training or due to discharge for administrative or medical reasons.
• Those leaving the Services within four years have been identified as being particularly vulnerable, particularly with regards to developing mental health problems (Iversen et al, 2005b).
• The recent resurgence of interest in what happens to those Service personnel who leave the UK Armed Forces has been greatly fuelled by the media. Coverage however has typically focused on the minority who fare badly and subsequently experience social exclusion on leaving the UK Armed Forces. What little empirical evidence exists suggest that the majority fare well. For example, analysis of the longitudinal outcomes for a cohort of service leavers from a large randomly selected military cohort showed that 87.5% of those who left the UK Armed Forces were in full-time employment (Iversen et al, 2005a). Moreover, the chances of employment were increased as a result of the "medal effect" of the tour of duty such that those who returned in good health from the 1991 Gulf War had a greater chance of being employed than those who had not been deployed (Iversen & Greenberg, 2009a). However, the findings also showed that a substantial minority of ex-Service personnel are at risk of social exclusion on leaving service due to mental health problems and chronic ill health.
• More recently, a unique study conducted by van Staden et al (2007) identified factors associated with poor outcomes for 74 military personnel leaving the UK Armed Forces prematurely. Being disadvantaged was associated with: (i) experiencing pre-discharge mental health problems, (ii) receiving an administrative discharge, and (iii) serving a short sentence in Colchester Military Corrective Training Centre prior to discharge. These young men reported difficulties in accessing available resettlement services due to: (i) an absence of knowledge about the availability of services, (ii) a negative perception regarding the helpfulness of services, and (iii) previous bad experiences with other services. Most of the small minority who sought help for their mental health problems preferred to use informal networks of support (e.g., family and friends). At six months post-discharge only one participant had sought help for his mental health problem.

5.4.7 Post-Service Outcomes

5.4.7.1 Veterans in prison

• As reported by a recent Royal British Legion literature review on UK Veterans and the criminal justice system (2011), few research studies have been conducted on Veterans in prisons in the UK, and there is considerable variation in the levels of incarceration reported. However, DASA in collaboration with the Ministry of Justice undertook a robust study, which sought to match the records held on a database of all prisoners in England and Wales with another database comprising the records of Regular UK Veterans in November 2009. This resulted in a total of 2,207 matches (i.e., 2.7% of the total prison population). However, because the records were incomplete prior to certain years for each of the tri-Services, the outcome of further analyses of the Veteran population in England and Wales was reported in 2010 with a revised estimated total number of 2,820 (i.e., 3.5% of the total prison population). The second DASA report also provided a unique profile of UK Veterans in prison, as follows.
  • Regular Veterans are 30% less likely to be in prison compared with non-Veterans.
  • Around 50% are aged between 18-44 years.
  • Only 1% are aged 75 years and above.
  • Only 1% held the rank of Officer.
  • The length of time between discharge from military service and the start of their custodial sentence ranged from 0-41 years with the majority (41%) beginning their current sentence within 10 years.
  • The most common offences were violence against a person and sexual offences (33% and 25% respectively). Drugs accounted for 11%.

A key finding was that, with the exception of sexual offences, the Regular Veteran population has a lower rate of offending than that of the general population in England and Wales.

• Fletcher (2007) reports that the majority of legal problems experienced by Veterans referred to Combat Stress treatment centres relate to excessive alcohol use and episodes of violent behaviour, which may be triggered by combat-related memories and is frequently an important underlying factor in relation to self-harm and attempted suicide. KCMHR are currently exploring the impact of deployment.
• Whilst there has been some research on suicide risk among Veterans in general (e.g., Kapur et al, 2009) and on suicide among inmates of prisons (e.g., Fazel et al, 2005) there remains a paucity of research literature on suicide among incarcerated Veterans (Wortzel et al, 2009). Thus, the suicide rate and the extent of excess risk remain unknown. Hence, meaningful estimates are not available. However, striking similarities and overlapping characteristics link the data on Veteran suicide, inmate suicide, and incarcerated Veterans, suggesting that Veterans in prison faces a higher level of suicide risk beyond that conferred by either Veteran status or incarceration alone. To this end, there is a clear need for a better characterisation of the incarcerated Veteran population and the suicide rate of this group.

5.4.7.2 Self-harm

• The UK has one of the highest self-harm rates in Europe affecting approximately 400 per 100,000 people (Horrocks et al, 2002). To define self-harm, however, is problematic because it comprises different types of behaviour, occurs in different contexts and holds different motivations and meaning for the individual concerned (Royal College of Psychiatrists, 2010). According to the National Collaborating Centre for Mental Health Guidelines (2004), self-harm is defined as: "Self-poisoning or self-injury, irrespective of the apparent purpose of the act". The most widely used definition in Europe and elsewhere refer to self-harm as: "Intentional acts of self-poisoning or self-injury irrespective of the type of motivation or degree of suicidal intent" (Hawton et al, 2007).
• Evidence from general UK population studies suggests that the most common form of self-injury is cutting, which is more repetitive than other forms of self-harm and, contrary to popular belief, is not more prevalent in females (Lilley et al, 2008). Men tend to choose more violent (and thus more likely to be lethal) suicide methods such as hanging, asphyxiation and firearms. Women, on the other hand, are more likely to choose self-poisoning. Another difference is the evidence that men die from suicide more frequently than do women (Hawton, 2000). In recent years, compared with females the suicide rates for males have increased, particularly in the younger age group (Cantor, 2000); a pattern which is especially marked in the UK (Hawton, 1992). These gender differences not only apply to the risk of suicidal behaviour, but also to its nature, causes, prevention and treatment. Further epidemiological studies of this kind are required to enhance understanding of the social and economic associations with suicidal behaviour in each gender. In addition, there is a need to generate information that can guide clinical practice and prevention strategies for preventing suicidal behaviours in both genders (Hawton, 2000).
• Few studies however have sought to undertake a systematic empirical evaluation of self-harm and suicide risk in the ex-Service population. Using qualitative research methods, Crawford et al (2009) sought to examine the context of suicidal behaviour among soldiers in the UK Armed Forces in order to identify preventative factors. In-depth interviews were conducted with 21 service providers to obtain data on: (i) factors predictive of suicidal behaviour among soldiers; (ii) methods used for deliberate self-harm; (iii) help-seeking behaviour before and after an episode of self-harm, and (iv) concomitant barriers to accessing support services. The data were subsequently cross-validated with interview data obtained from 10 Service personnel who had received treatment from staff at DCMHs following an episode of deliberate self-harm (DSH). A key issue to emerge from the findings of the Crawford et al (2009) qualitative study is the need to focus on efforts to reduce stigmatisation of mental illness within the military and specifically with regard to the role of the Commanding Officers. Crawford et al (2009) also suggested that more needs to be done with regards to raising awareness about existing sources of help and to reduce levels of alcohol misuse. In view of the evidence that prior self-harm behaviour elevates the risk of subsequent suicide by 100 times (Jenkins et al, 2002), the need for further research in this domain has been highlighted by Dandeker et al (2003). Such research should also include identifying the gender differences in DSH given the evidence which shows that women more often engage in DSH than do men (Hawton, 2000).
• Thoresen & Mehlum (2006) reported on the investigation of risk factors for suicide in Veterans of peacekeeping duties. A total of 43 suicides and 41 fatal accidents in Norwegian peacekeepers (1978 to 1995) were compared in a psychological autopsy study. Mental health problems were the most important risk factor for suicide. Both living alone and the break-up of a marital relationship contributed uniquely to suicide risk, even when controlling for mental health problems. No peacekeeping-related factor was associated with suicide. On the basis of these findings, the authors suggested that preventive measures should focus on firearms control, improved detection systems for mental health problems in the military, and peer support through Veterans' associations.
• Kapur et al (2009) conducted a unique retrospective cohort study of ex-Service personnel who had left the UK Armed Forces between 1996 and 2005. By linking national databases^[177] of Service leavers and suicide deaths^[178], the Veteran cohort was compared with an age-matched general population in order to investigate the:
  • rate of suicide in Veterans;
  • timing of suicide in respect of the time elapsed since discharge;
  • potential risk factors for death by suicide, and
  • rates of contact with mental health services prior to suicide (and to generate a profile of those who make contact with those services).
• Covering the whole of the UK and the three Services, Kapur et al (2009) obtained data on 233,803 Veterans who had left the UK Armed Forces between 1 April 1996 and 31 December 2005; a figure representing nearly all (>98%) of all those who had been discharged during that time period. The median age of the cohort was 25 years and the majority were male (90%) and had served in the Army (59%). Medical discharge was recorded as the reason for leaving for some 7% of those identified. In total 224 (0.095%) were found to have taken their lives after leaving service, the majority of whom did so by strangulation (44%). Few deaths (5%) involved the use of a firearm. In the main the methods of suicide did not differ significantly from those found in the general population. In interpreting this finding however it is important to bear in mind that one of the most commonly reported differences in male and female suicide behaviours is which method of suicide they select.
• Although, the overall rate of suicide of Veterans reported by Kapur et al (2009) was not found to exceed that of the general population, the risk of suicide in the two youngest age groups (under 20 years and 20 to 24 years) was around two to three times greater than in those in the general population who fell within these two age groups. The risk of suicide in Veterans was found to be higher in males, those who had served in the Army, those with a shorter length of service, and those of lower rank. Risk of suicide was greatest in the first two years after leaving Service. Twenty one per cent of the 224 Veterans who had committed suicide had made contact with the mental health services in the year preceding the event, a figure which was slightly less than for those in the general population who had also approached the mental health services in the same time period. Kapur et al (2009) proposed that the higher rate of suicide found in younger individuals after leaving service could be due to:
  • problems associated with the transition from military to civilian life,
  • exposure to adverse experiences whilst in-Service, or
  • pre-service vulnerability factors.
• Whilst it was not possible to ascertain which of the above was the most likely cause, the Kapur et al (2009) findings support evidence of:
  • the relationship between pre-service vulnerability and ill health (e.g., Iversen et al, 2007), and
  • difficulties in the accessibility or acceptability of NHS mental health services (e.g., Iversen et al, 2005b).

Another contributory factor which has not been investigated in the Veteran population is the increased vulnerability of those who have been released from prison.

• The retrospective evaluation of suicide however is inevitably restricted to those data that are available from routine records and other secondary databases. Thus, whilst such data can be used to quantify the strength of association between risk factors and suicide, they are limited in terms of permitting an understanding of the context in which suicidal behaviour occurs.
• Another key issue, which could not be addressed by Kapur et al (2009), relates to identifying the extent to which military service is a protective factor. Given that there is evidence that military service can have a positive effect on various outcomes including employment [e.g., Iversen et al, 2005b]), it may also be the case with regards to helping to prevent suicide. In considering the benefit of their findings in terms of the existing service provision for health and welfare support of Veterans in the UK, Kapur et al (2009) emphasise the importance of recognising that those individuals who are selected out of service during the preliminary stages of enlistment (from the initial pre-recruitment interview through to training) may be at increased risk of detrimental outcomes (which would also include suicide).
• The identification of a vulnerable group also highlights the need for targeted interventions with a view to saving lives. Sareen and Belik (2009) highlight one example of a programme that was specifically targeted at an at-risk military population, which was initiated by the US Air Force in 1996^[179]. The purpose of that programme was to: (i) educate military personnel about suicide prevention strategies; (ii) help military personnel to manage their emotional reactions post-trauma; (iii) provide referral guidelines for Commanding Officers for mental health services. An evaluation of the programme based on data derived from a cohort study found that its implementation was associated with a 33% relative risk reduction in suicide (Knox et al, 2003).
• One of the more general public health strategies highlighted in a recent systematic review of suicide prevention programmes (Mann et al, 2005) includes the safe media reporting of suicides. This is particularly pertinent in the UK where there has been a plethora of dramatic media portrayals of suicide in soldiers and Veterans^[180]. Whether or not such sensationalised media coverage elevates the risk of copycat suicides is subject to debate (PloS Medicine Editors, 2009). However, for the reasons highlighted by Dandeker et al (2005), such press coverage has a potentially detrimental effect on the image of the UK Armed Forces and public support, which in turn may have recruitment implications. As highlighted by Alexander and Klein (2006), it is also important to bear in mind however that the media can potentially make a major contribution in terms of education, information, and destigmatisation. To our knowledge, however, this is an area that has not been subject to empirical investigation.

5.4.7.3 Barriers to mental healthcare

• There is an increasing acknowledgement of the need to address barriers to mental health care by the military given that untreated mental health problems have a substantial impact on both individual well-being and operational effectiveness of the fighting force (Hoge et al, 2002). Yet, despite efforts to enhance access to mental health services for both service and ex-service personnel research findings from both the US (e.g., Milliken et al, 2007) and the UK (e.g., Iversen et al, 2005b) indicate that the majority do not seek help from these services. A recent US review by Vogt (2011) highlights the extent to which research on barriers to mental health care for military health personnel and Veterans has burgeoned revealing a number of factors that substantially affect service use and health and well-being outcomes. In respect of the UK, Fletcher (2007) states that:

"Barriers to obtaining help include the stigma attached to mental health problems, military ethos, NHS mental health services that are configured to prioritise severe enduring mental illness, and problems for Veterans in engaging with treatment services that have very little understanding of military culture or combat-related psychological trauma." p.92.

5.4.7.4 Lack of integration across services

• Hoge et al (2006) described a substantial degree of psychopathology among Veterans returning from Iraq and Afghanistan and the barrier to adequate care. Potential targets for intervention involve the multiple periods of transition faced by returning Veterans. As individuals move from one system of care to another, treatment lapses commonly occur, and critical information may be lost in transit. Integration across services and systems has been identified as crucial in ensuring an effective mental health system.

5.4.7.5 Durability of therapeutic gain

• A major challenge for any therapeutic regimen is to attain durability of positive changes. Outcome research conducted on Veterans referred to Combat Stress (Fletcher, 2007) showed that positive gains achieved through the efforts of Combat Stress to address the complex needs of Veterans with mental health problems were frequently short term for a variety of reasons including limited resources. Furthermore, 75% experience more than one diagnosis, which can make it difficult for GPs of psychiatric services to manage the typically severe and complex mental health problems presented by this potentially vulnerable population (Fletcher, 2007).

5.4.7.6 Stigma

• Evidence suggests that the stigma associated with mental health problems (and resulting discrimination) is as much a problem for Service and ex-Service personnel as those who experience such problems in general population (Fossey, 2010). Stigma has been variously described in the literature as a "mark or sign of disgrace or discredit" (Oxford English Dictionary) to "an attribute that is deeply discrediting and that reduces the bearer from a whole and usual person to a tainted, discounted one" (Goffman, 1963, p3). Mental health experts suggest that it refers to the "negative effects of a label placed on any group including those who have been diagnosed as having mental health problems" (Hayward & Bright, 1997).
• Iversen et al (2011) conducted a cross sectional study of 821 participants to compare barriers to care in: (i) Regulars, Reservists and Veterans (i.e. those who had left the UK Armed Forces) and (ii) those individuals diagnosed with and without a current mental health diagnosis. Drawing on the existing KCMHR military cohort, the sample was stratified by deployment history and Regular/ Reserve status. Stigma associated with a mental health problem presented as the most common barrier to care along with the practicalities of consulting (e.g. arranging an appointment and getting time off work for treatment). Even after leaving the Service, barriers to care persisted for ex-Service personnel particularly in terms of identifying where to obtain help and a fear that employers would not be sympathetic to their problems. Compared to those without a diagnosis of a mental disorder, those with a diagnosis were more likely to report barriers to care. These findings suggest that stigma and practical barriers to care persist and prevent Service and ex-Service personnel from getting help regardless of recent endeavours by the UK Armed Forces to remove the stigma associated with mental disorders in the military. On this basis, Iversen et al (2011) call for the prioritisation of further interventions to address this issue in order to facilitate help seeking in Service personnel for mental health problems. Such interventions include outreach and formal educational programmes to reduce the stigma of help seeking as well as ensuring that the chain of command actively encourage those at high risk (e.g., returning from operational duties) to seek help.

5.4.7.7 Help seeking

• Evidence suggests that there is a significant reluctance by Veterans to seek help on leaving the service (Iversen et al, 2005a). In addition, the decline in civilian-military understanding may have had an adverse impact on the way in which Veterans are capable of dealing with civilian agencies (Deahl et al, 2011).
• Iversen et al (2005a) conducted a study to establish the frequency and associations of common mental disorders and help-seeking behaviours in a representative sample of UK Veterans who were deemed to be at high risk of developing mental health problems. By means of a structured interview 43.8% of the sample was found to have one or more psychiatric diagnoses, the most common of which were depressive-spectrum disorders. In comparison, PTSD accounted for 16.3 % of the psychiatric diagnoses identified although the majority (75.5%) of these also had a comorbid diagnosis including probable alcohol dependence (34.7%). Only 3.3% of PTSD diagnoses were made by primary care practitioners with the majority made by military psychiatrists (30%). Approximately a third of the sample declared by self report that they had suffered a mental problem whilst in Service, the predominant problems of which were depression (48.3%) and stress (37.9%). Those with a psychiatric diagnosis compared with those without were more likely to be of lower rank, single and served in the Army. Fifty per cent who had a psychiatric diagnosis had sought help with the majority consulting their medical officer (69.6%). "Embarrassment or stigma" accounted for the main reason why the other 50% had not sought help. On leaving Service, 58.4% with self reported mental health problems were currently seeking help in the main from their general practitioners (86.9%). Fear of stigma and embarrassment (20%) and the belief that they could self manage their problems (72%) were reported by non help seekers. The majority of help seekers received treatment (83%) mostly in the form of medication (70%). A fifth of the help seekers were in contact with a Service charity and only 4% were being treated with cognitive-behavioural therapy. Overall, the majority (95.9%) of participants were employed although, compared to those individuals without a current diagnosis, those with a current diagnosis had experienced longer periods of unemployment and had changed their jobs more frequently. There are three limitations of this study which need to be considered in determining the implications of these findings. First, the reliance on retrospective self report is subject to recall bias and potential inaccuracies. Second, as a random sample of vulnerable Veterans was not used there is the potential likelihood that individuals who were more at risk of social exclusion and mental health problems were missed due to lack of compliance and difficulties in tracing Veterans. Third, because the sample derives from a cohort of individuals who served in the UK Armed Forces in 1991, the findings may not generalise to earlier or later military cohorts.
• Iversen et al (2010) examined healthcare service use and receipt of treatment in a sample of participants drawn from the existing KCMHR cohort. Stratified by Reserve status and by participation in the main war-fighting period of the Iraq war, this cross-sectional study used a structured telephone-administered interview along with standardised diagnostic measures and a series of questions regarding the use of services and the receipt of treatment. Around a fifth of those with common mental disorders who were currently serving in the UK Armed Forces reported receiving any form of help from a healthcare professional. Most relied on non-medical sources of help such as military chaplains. Of those Regular personnel who had received professional help, primary care provided the most common source of help (79%) and medication or counselling/ psychotherapy was the most common form of treatment. A minority received cognitive behavioural therapy. The low rates of help-seeking from medical sources and receipt of treatment are similar to those reported for US military personnel and the UK general population. These findings highlight further the need to understand barriers to care in light of the fact that a significant minority of Service personnel are at risk of "occupational psychiatric injury". Furthermore, of significance in meeting the mental health needs of ex-Service personnel is the evidence which suggests that the main reason why individuals do not access services is based on the belief that they do not need help at a much earlier point in the care pathway. This finding challenges the previously held assumption that the unmet burden of mental health problems in Service and ex-Service personnel is due to the unavailability of suitable services. Thus, further research and evaluation is required to develop interventions which would enable Service personnel to recognise common mental health problems that require professional treatment and to reduce the stigma associated with seeking help for such problems within the military.
• Jones et al (2011) conducted a follow-up study of Reservists who had accessed the RMHP during the initial three years of clinical activity (November 2006 to November 2009) to compare mental health outcomes in a treatment group with operationally attributable mental health problems versus a non-intervention group with non-operationally attributable problems. Self report measures of PTSD, common mental health disorders, alcohol use and occupational functioning were delivered either by telephone of post to a sample of 83 Reservists. The majority of these RMHP attendees were from the Army. In comparison with the Regular Army, the sample were older in age and included relatively more combat troops than the Army as a whole, and a higher number of Junior NCOs and Warrant Officers. Approximately half of the sample had completed a minimum of one tour of operational duty the majority of which was for 6 months duration (85%). For one third the last tour was completed in Afghanistan. The treatment group were more likely than the non treatment group to be cases at baseline on all the mental health outcome measures with the exception of PTSD. This difference however did not persist at follow-up. On completion of treatment the majority (76.5%) of the Mobilised Reserve Force personnel resumed full occupational fitness whereas 14.9% were medically discharged from the UK Armed Forces. The findings from this clinical evaluation counter concerns that the RMHP could be at risk of overload from personnel who seek help for non operationally-related mental health problems. Despite the relatively small number of personnel who accessed the RMHP, the evidence suggests effective mental health and occupational outcomes on completion of treatment comprising short-term psychotherapy or medication. The findings from this study however need to be treated with caution in light of the incomplete dataset, low response rate and restriction of the measurement of clinical outcomes only of those who accessed the RMHP. Those Reserve personnel requiring further treatment were predominantly suffering from an adjustment disorder, probable PTSD or depressive disorder, which is not dissimilar to their Regular force counterparts (Gould et al, 2008). Given that the majority of personnel used self-referral rather than accessing the system via their general practitioner, the authors suggest that open access for Regular forces to speciality services may address the issue of stigma and barriers to care identified by other studies (e.g., Gould et al, 2010) as is the case with improving access to psychological therapies (Clark et al, 2009).