COVID-19 survey burden for health care workers: literature review and audit.

OBJECTIVES: Concerns have been raised about the quantity and quality of research conducted during the COVID-19 pandemic, particularly related to the mental health and wellbeing of health care workers (HCWs). For understanding the volume, source, methodological rigour and degree of overlap in COVID-19, studies were conducted among HCWs in the United Kingdom (UK). STUDY DESIGN: Mixed methods approach, literature review and audit. METHODS: First, a literature review of published research studies and second, an audit of studies HCWs have been invited to complete. For the literature review, we searched Medline, PsycINFO and Nexis, webpages of three medical organisations (Royal Society of Medicine, Royal College of Nursing and British Medical Association), and the YouGov website. For the audit, a non-random purposive sample of six HCWs from different London NHS Trusts reviewed email, WhatsApp and SMS messages they received for study invitations. RESULTS: The literature review identified 27 studies; the audit identified 70 study invitations. Studies identified by the literature review were largely of poor methodological rigour: only eight studies (30%) provided response rate, one study (4%) reported having ethical approval, and one study (4%) reported funding details. There was substantial overlap in the topics measured. In the audit, volunteers received a median of 12 invitations. The largest number of study invitations were for national surveys (n = 23), followed by local surveys (n = 16) and research surveys (n = 8). CONCLUSION: HCWs have been asked to complete numerous surveys that frequently have methodological shortcomings and overlapping aims. Many studies do not follow scientific good-practice and generate questionable, non-generalisable results.

Military and demographic predictors of mental ill-health and socioeconomic hardship among UK veterans.

BACKGROUND: Around 8% of the UK Armed Forces leave in any given year, and must navigate unfamiliar civilian systems to acquire employment, healthcare, and other necessities. This paper determines longer-term prevalences of mental ill health and socioeconomic outcomes in UK Service leavers, and how they are related to demographic factors, military history, and pre-enlistment adversity. METHODS: This study utilised data from a longitudinal sample of a cohort study UK Armed Forces personnel since 2003. A range of self-reported military and sociodemographic factors were analysed as predictors of probable Post-Traumatic Stress Disorder, common mental disorders, alcohol misuse, unemployment and financial hardship. Prevalences and odds ratios of associations between predictors and outcomes were estimated for regular veterans in this cohort. RESULTS: Veteran hardship was mostly associated with factors linked to socio-economic status: age, education, and childhood adversity. Few military-specific factors predicted mental health or socio-economic hardship, except method of leaving (where those leaving due to medical or unplanned discharge were more likely to encounter most forms of hardship as veterans), and rank which is itself related to socioeconomic status. CONCLUSION: Transition and resettlement provisions become increasingly generous with longer service, yet this paper shows the need for those services becomes progressively less necessary as personnel acquire seniority and skills, and instead could be best targeted at unplanned leavers, taking socioeconomic status into consideration. Many will agree that longer service should be more rewarded, but the opposite is true if provision instead reflects need rather than length of service. This is a social, political and ethical dilemma.

Characteristics of patients with motor functional neurological disorder in a large UK mental health service: a case-control study.

BACKGROUND: Functional neurological disorder (FND), previously known as conversion disorder, is common and often results in substantial distress and disability. Previous research lacks large sample sizes and clinical surveys are most commonly derived from neurological settings, limiting our understanding of the disorder and its associations in other contexts. We sought to address this by analysing a large anonymised electronic psychiatric health record dataset. METHODS: Data were obtained from 322 patients in the South London and Maudsley NHS Foundation Trust (SLaM) who had an ICD-10 diagnosis of motor FND (mFND) (limb weakness or disorders of movement or gait) between 1 January 2006 and 31 December 2016. Data were collected on a range of socio-demographic and clinical factors and compared to 644 psychiatric control patients from the same register. RESULTS: Weakness was the most commonly occurring functional symptom. mFND patients were more likely to be female, British, married, employed pre-morbidly, to have a carer and a physical health condition, but less likely to have had an inpatient psychiatric admission or to receive benefits. No differences in self-reported sexual or physical abuse rates were observed between groups, although mFND patients were more likely to experience life events linked to inter-personal difficulties. CONCLUSIONS: mFND patients have distinct demographic characteristics compared with psychiatric controls. Experiences of abuse appear to be equally prevalent across psychiatric patient groups. This study establishes the socio-demographic and life experience profile of this understudied patient group and may be used to guide future therapeutic interventions designed specifically for mFND.

Hospital admissions for non-communicable disease in the UK military and associations with alcohol use and mental health: a data linkage study.

BACKGROUND: Since the recent conflicts in Iraq and Afghanistan, the short-term focus of military healthcare research has been on the consequences of deployment for mental health and on those wounded or injured in combat. Now that these conflicts have ended for the UK Armed Forces, it is important to consider the longer term physical and mental health consequences, and just as importantly, the links between these. The aims of this study were to determine the most common physical conditions requiring a hospital admission in UK military personnel and whether they were more common in personnel with a mental health condition, smokers, and/or those misusing alcohol compared to those without. METHODS: Data linkage of a prospective UK military cohort study to electronic admitted patient care records for England, Wales and Scotland. Nine thousand nine hundred ninety military personnel completed phase 2 of a military cohort study (56% response rate, data collected from 2007 to 2009), with analyses restricted to 86% of whom provided consent for linkage to healthcare records (n = 8602). Ninety percent were male and the mean age at phase 2 was 36 years. The outcome was physical non communicable diseases (NCDs) requiring a hospital admission which occurred after phase 2 of the cohort when the mental health, smoking and alcohol use exposure variables had been assessed until the end of March 2014. RESULTS: The most common NCDs requiring a hospital admission were gastrointestinal disorders 5.62% (95% Confidence Intervals (CI) 5.04, 6.19) and joint disorders 5.60% (95% CI 5.02, 6.18). Number of NCDs requiring a hospital admission was significantly higher in those with a common mental disorder (Hazard ratio (HR) 1.40 (95% CI 1.16-1.68), post-traumatic stress disorder (HR 1.78 (95% CI 1.32-2.40)) and in current smokers (HR 1.35 (95% CI 1.12-1.64) compared to those without the disorder, and non-smokers, respectively. CONCLUSIONS: Military personnel with a mental health problem are more likely to have an inpatient hospital admission for NCDs compared to those without, evidencing the clear links between physical and mental health in this population.

UK military women: mental health, military service and occupational adjustment.

BACKGROUND: Recently, the UK Armed Forces have revised the ground close combat role to include women. AIMS: To assess the potential mental health impact of this initiative we examined gender differences in deployment patterns, work strain, occupational factors, mental health, alcohol use and help-seeking following operational deployment. METHODS: The study was a secondary analysis of self-report survey data; 8799 men (88%) and 1185 women (12%) provided data. A sub-sample (47%, n = 4659) provided data concerning post-deployment help-seeking. The latter consisted of 408 women (8.8%) and 4251 men (91%). RESULTS: With the exception of alcohol misuse, which was significantly lower for women, women reported significantly more common mental disorder symptoms, subjective depression and self-harm. Women were significantly more likely to seek help from healthcare providers. Men were significantly more likely to have deployed operationally and for longer cumulative periods. Subjective work strain, but not job control, was significantly lower for women whose military careers were significantly shorter. Post-traumatic stress disorder (PTSD) symptom intensity was similar to men. CONCLUSIONS: With the exception of PTSD and alcohol misuse, UK military women experience more mental health-related problems than military men. This finding was not related to the more arduous aspects of military service as women served for shorter times, deployed less and for shorter cumulative periods and were less likely to report work-related stress.

How to improve adherence with quarantine: rapid review of the evidence.

OBJECTIVES: The December 2019 outbreak of coronavirus has once again thrown the vexed issue of quarantine into the spotlight, with many countries asking their citizens to 'self-isolate' if they have potentially come into contact with the infection. However, adhering to quarantine is difficult. Decisions on how to apply quarantine should be based on the best available evidence to increase the likelihood of people adhering to protocols. We conducted a rapid review to identify factors associated with adherence to quarantine during infectious disease outbreaks. STUDY DESIGN: The study design is a rapid evidence review. METHODS: We searched Medline, PsycINFO and Web of Science for published literature on the reasons for and factors associated with adherence to quarantine during an infectious disease outbreak. RESULTS: We found 3163 articles and included 14 in the review. Adherence to quarantine ranged from as little as 0 up to 92.8%. The main factors which influenced or were associated with adherence decisions were the knowledge people had about the disease and quarantine procedure, social norms, perceived benefits of quarantine and perceived risk of the disease, as well as practical issues such as running out of supplies or the financial consequences of being out of work. CONCLUSIONS: People vary in their adherence to quarantine during infectious disease outbreaks. To improve this, public health officials should provide a timely, clear rationale for quarantine and information about protocols; emphasise social norms to encourage this altruistic behaviour; increase the perceived benefit that engaging in quarantine will have on public health; and ensure that sufficient supplies of food, medication and other essentials are provided.

Drinking motivations in UK serving and ex-serving military personnel.

BACKGROUND: Drinking motivations within the UK military have not been studied despite the high prevalence of alcohol misuse in this group. AIMS: We aimed to characterize drinking motivations and their demographic, military and mental health associations in UK serving and ex-serving personnel. METHODS: Serving and ex-serving personnel reporting mental health, stress or emotional problems occurring in the last 3 years were selected from an existing cohort study. A semi-structured telephone interview survey examined participants' mental health, help-seeking, alcohol use and drinking motivations. RESULTS: Exploratory factor analysis of drinking motivations in military personnel (n = 1279; response rate = 84.6%) yielded 2 factors, labelled 'drinking to cope' and 'social pressure'. Higher drinking to cope motivations were associated with probable anxiety (rate ratio [RR] = 1.4; 95% confidence interval [CI] = 1.3-1.5), depression (RR = 1.3; 95% CI = 1.2-1.4) and post-traumatic stress disorder (RR = 1.4; 95% CI = 1.3-1.6). Higher social pressure motivations were associated with probable anxiety (odds ratio = 1.1; 95% CI = 1.0-1.1). Alcohol misuse and binge drinking were associated with reporting higher drinking to cope motivations, drinking at home and drinking alone. CONCLUSIONS: Amongst military personnel with a stress, emotional or mental health problem, those who drink to cope with mental disorder symptoms or because of social pressure, in addition to those who drink at home or drink alone, are more likely to also drink excessively.

British military women: combat exposure, deployment and mental health.

BACKGROUND: Internationally, women are about to undertake combat duties alongside their male colleagues. The psychological effect of this policy change is largely unknown. AIMS: To explore the mental health impact of combat exposure among military women. METHODS: Self-report, between-subjects survey data were collected in Iraq and Afghanistan on four occasions between 2009 and 2014 (n = 4139). Differences in mental health, stigmatization, deployment experiences, intimate relationship impact, perception of family support levels, unit cohesion, leadership and help-seeking were compared between deployed men and women. Comparisons were repeated with the study sample stratified by level of combat exposure. Outcomes were examined using logistic regression adjusted for socio-demographic, mental health and military factors. RESULTS: Overall, 4.1% of women and 4.3% of men reported post-traumatic stress disorder (PTSD) (odds ratio (OR) 1.31, 95% confidence interval (95% CI) 0.70-2.46); 22% of women and 16% of men reported symptoms of common mental disorder (CMD) (OR 1.52, 95% CI 1.11-2.08). Women were less likely to report mental health-related stigmatization (OR 0.68, 95% CI 0.53-0.87), negative relationship impact from deployment (OR 0.69, 95% CI 0.49-0.98) and subjective unit cohesion (OR 0.69, 95% CI 0.53-0.90). Help-seeking for emotional problems was similar by gender (OR 1.22, 95% CI 0.84-1.77). Overall, outcomes were minimally impacted by level of combat exposure. CONCLUSIONS: Although women experienced more CMD symptoms, PTSD symptoms were similar by gender. Subject to confirmation of the study findings, women may not require enhanced mental healthcare during deployment for exposure-based conditions such as PTSD when undertaking the ground close combat role.

Experiences and career intentions of combat-deployed UK military personnel.

Background: Most studies of the psychological impact of military deployment focus on the negative and traumatic aspects. Less is known about the full range of deployment experiences nor how these may impact on career intentions. Aims: To examine subjective operational experiences and career intentions in deployed UK military personnel using data gathered toward the end of an operational deployment. Methods: Data were gathered during deployment in Iraq and Afghanistan. A self-report survey collected data on sociodemographic, operational and military factors. Respondents provided their strength of agreement or disagreement with six potentially positive deployment experiences and their endorsement or rejection of six possible career intentions. Two mental health measures assessed symptoms of common mental disorder and post-traumatic stress disorder. Results: Responses were 681 in Iran 2009 (100% response rate); 1421 in Afghanistan in 2010 (100%), 1362 in 2011 (96%) and 860 in 2015 (91%). Five of the potentially positive outcomes were endorsed by >50% of the sample: confidence about remaining healthy after returning home, pride in accomplishments, increased confidence in abilities, improved unit cohesion and experiencing a positive life effect. Ninety per cent of respondents planned to continue in service after returning home. Fewer positive deployment experiences, poorer mental health, lesser unit cohesion and more negative impressions of leadership were significantly associated with intention to leave service. Conclusions: Contrary to the popular belief that UK military personnel deployed to Iraq or Afghanistan experience negative outcomes, this paper shows that deployment can be a positive experience for a substantial majority of deployed personnel.

Post-traumatic stress disorder and alcohol misuse: comorbidity in UK military personnel.

AIMS: To determine the prevalence of comorbid probable post-traumatic stress disorder and alcohol misuse in a UK military cohort study and to determine the level of co-occurrence between these disorders; further aims were to investigate the association between alcohol misuse and the different PTSD symptom clusters, and to assess what factors are associated with probable PTSD in participants with alcohol misuse. METHODS: Data from 9984 participants of Phase 2 of the health and well-being survey of serving and ex-serving members of the UK Armed Forces were assessed for probable PTSD and alcohol misuse using the PTSD checklist (PCL-C) and the alcohol use disorders identification test (AUDIT), respectively. RESULTS: 1.8 % [95 % confidence interval (CI) 1.5-2.1] of the sample met the criteria for both PTSD and alcohol misuse. All three symptom clusters of PTSD were significantly associated with alcohol misuse, with similar odds ranging from 2.46 to 2.85. Factors associated with probable PTSD in individuals reporting alcohol misuse were age [ages 30-34 (years): OR 2.51, 95 % CI 1.15-5.49; ages 40-44 years: OR 2.77, 95 % CI 1.18-6.47], officer rank (OR 0.36, 95 % CI 0.16-0.85), being in a combat role in parent unit (OR 1.99, 95 % CI 1.20-3.31) and common mental disorder (CMD) (OR 21.56, 95 % CI 12.00-38.74). CONCLUSIONS: This study provides strong evidence that PTSD and alcohol misuse are often co-occurring. CMD was highly associated with probable PTSD in individuals with alcohol misuse.

Are common mental disorders more prevalent in the UK serving military compared to the general working population?

BACKGROUND: Although the military is considered to be a stressful occupation, there are remarkably few studies that compare the prevalence of common mental disorder (CMD) between the military and the general population. This study examined the prevalence of probable CMD in a serving UK military sample compared to a general population sample of employed individuals. METHOD: Data for the general population was from the 2003 and 2008 collections for the Health Survey for England (HSE) and for the serving military from phases 1 (2004-2006) and 2 (2007-2009) of the King's Centre for Military Health Research (KCMHR) cohort study. Probable CMD was assessed by the General Health Questionnaire (GHQ-12). The datasets were appended to calculate the odds of CMD in the military compared to the general population. RESULTS: The odds of probable CMD was approximately double in the military, when comparing phase 1 of the military study to the 2003 HSE [odds ratio (OR) 2.4, 95% confidence interval (CI) 2.1-2.7], and phase 2 to the 2008 HSE (OR 2.3, 95% CI 2.0-2.6) after adjustment for sex, age, social class, education and marital status. CONCLUSIONS: Serving military personnel are more likely to endorse symptoms of CMD compared to those selected from a general population study as employed in other occupations, even after accounting for demographic characteristics. This difference may be partly explained by the context of the military study, with evidence from previous research for higher reports of symptoms from the GHQ in occupational compared to population studies, in addition to the role of predisposing characteristics.

Risk-taking behaviours among UK military reservists.

BACKGROUND: Deploying in a combat role negatively impacts risk-taking behaviours, such as drinking, smoking and risky driving in regular UK military personnel. Little is known about the impact of deployment on the risk-taking behaviours of reservists. AIMS: To explore the impact of deployment on risk-taking behaviours among reservists. METHODS: This was a cross-sectional study. Hazardous drinking, risky driving, physical violence, smoking and attendance at accident and emergency (A&E) departments as a result of risk-taking behaviours were assessed by self-reported questionnaire. RESULTS: There were 1710 participants in the study; response rate 51%. The overall prevalence of risk-taking behaviours was: hazardous drinking 46%, smoking 18%, risky driving 11%, attending A&E due to risky behaviours 13% and reporting physical violence 3%. Deployment was significantly associated with risky driving [odds ratio (OR) 1.88, 95% confidence interval (CI) 1.25-2.81], smoking (OR 2.02, 95% CI 1.46-2.78) and physical violence (OR 3.63, 95% CI 1.88-7.02). CONCLUSIONS: It is important to consider the impact of deployment and military factors on the prevalence of risk-taking behaviours in reservists as greater numbers than ever before will face the prospect of deployment to overseas conflicts.

Mental health of UK Armed Forces medical personnel post-deployment.

BACKGROUND: The mental health effects of deployment vary widely, and personnel in both combat and combat support roles, including medical personnel, may be adversely affected. AIMS: To compare the mental health of deployed UK military medical staff in both forward and rear locations and to compare these two groups with other deployed military personnel. METHODS: Participants were medics who had deployed to Iraq or Afghanistan and provided information about their deployed role, experiences during and on return from deployment and demographic and military factors. Health outcomes included common mental health problems (using 12-item General Health Questionnaire), post-traumatic stress disorder (PTSD, using 17-item Post-Traumatic Stress Disorder Checklist-Civilian Version), multiple physical symptoms and alcohol use (using 10-item Alcohol Use Disorders Identification Test). RESULTS: The sample comprised 321 medical personnel. The response rate was 56%. The mental health outcomes for forward located medics (FMs) were no different than those for rear located medics (RLMs). When comparing FMs and RLMs against all other military roles, a small but significant increase in PTSD symptoms in FMs was found. FMs were more likely to rate their work while deployed as being above their skills and experience, report exposure to more combat experiences and report a more challenging homecoming experience than RLMs. CONCLUSIONS: These results suggest that while the overall rates of self-reported mental health disorders were similar in FMs and RLMs, FMs reported more PTSD symptoms than all other roles, which may have been related to working in more hostile environments in more challenging roles while deployed and their experiences on returning home.

Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence?

There is a commonly held perception in psychology that enquiring about suicidality, either in research or clinical settings, can increase suicidal tendencies. While the potential vulnerability of participants involved in psychological research must be addressed, apprehensions about conducting studies of suicidality create a Catch-22 situation for researchers. Ethics committees require evidence that proposed studies will not cause distress or suicidal ideation, yet a lack of published research can mean allaying these fears is difficult. Concerns also exist in psychiatric settings where risk assessments are important for ensuring patient safety. But are these concerns based on evidence? We conducted a review of the published literature examining whether enquiring about suicide induces suicidal ideation in adults and adolescents, and general and at-risk populations. None found a statistically significant increase in suicidal ideation among participants asked about suicidal thoughts. Our findings suggest acknowledging and talking about suicide may in fact reduce, rather than increase suicidal ideation, and may lead to improvements in mental health in treatment-seeking populations. Recurring ethical concerns about asking about suicidality could be relaxed to encourage and improve research into suicidal ideation and related behaviours without negatively affecting the well-being of participants.

Subjective cognitive complaints across the adult life span: a 14-year analysis of trends and associations using the 1993, 2000 and 2007 English Psychiatric Morbidity Surveys.

BACKGROUND: Cognitive complaints are common in all age groups but most often researched in old age. We aimed to investigate prevalences and time trends over 14 years of subjective memory complaints (SMC) and subjective concentration complaints (SCC) in adults and investigate associations with mood disorders and cognitive function. METHOD: Data from three English national mental health surveys carried out in 1993, 2000 and 2007 were analysed. SMC and SCC were measured using the Clinical Interview Schedule-Revised and cognitive function using the modified Telephone Interview for Cognitive Status. RESULTS: Both SMC and SCC increased up to middle age and then declined, followed by a second rise in the very oldest age groups. Age-specific prevalence of both increased across survey years but relationships with mental health and cognitive outcomes were relatively stable. CONCLUSIONS: Cognitive complaints are most common in middle age and have become more prevalent over time.

Sociodemographic and career history predictors of suicide mortality in the United States Army 2004-2009.

BACKGROUND: The US Army suicide rate has increased sharply in recent years. Identifying significant predictors of Army suicides in Army and Department of Defense (DoD) administrative records might help focus prevention efforts and guide intervention content. Previous studies of administrative data, although documenting significant predictors, were based on limited samples and models. A career history perspective is used here to develop more textured models. METHOD: The analysis was carried out as part of the Historical Administrative Data Study (HADS) of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). De-identified data were combined across numerous Army and DoD administrative data systems for all Regular Army soldiers on active duty in 2004-2009. Multivariate associations of sociodemographics and Army career variables with suicide were examined in subgroups defined by time in service, rank and deployment history. RESULTS: Several novel results were found that could have intervention implications. The most notable of these were significantly elevated suicide rates (69.6-80.0 suicides per 100 000 person-years compared with 18.5 suicides per 100 000 person-years in the total Army) among enlisted soldiers deployed either during their first year of service or with less than expected (based on time in service) junior enlisted rank; a substantially greater rise in suicide among women than men during deployment; and a protective effect of marriage against suicide only during deployment. CONCLUSIONS: A career history approach produces several actionable insights missed in less textured analyses of administrative data predictors. Expansion of analyses to a richer set of predictors might help refine understanding of intervention implications.

Perceptions of the impact a military career has on children.

BACKGROUND: The perceived effects of a military career on service personnel's children have been largely overlooked. AIMS: To examine the views of military personnel about the impact their career has on their children in relation to socio-demographic variables, military characteristics and mental health symptoms. METHODS: Service personnel (regular and reserve) with one or more children (<18 years) were included. Data were taken from a large UK military cohort study completed between 2007 and 2009. Participants were asked to report whether they viewed their military career as having a positive, negative or no impact on their children. RESULTS: There were 3198 participants. Just over half (51%) of service personnel perceived their military career as having a negative impact on their children. Not being in a relationship (multinomial odds ratio 2.65, 95% CI 1.81-3.88), deployment for 13 months or more within a 3 year period (1.85, 1.31-2.62), symptoms of common mental health disorder (2.21, 1.65-2.96) and probable post-traumatic stress disorder (3.26, 1.39-7.66) were associated with perceiving military career as affecting children negatively. Reserves were less likely than regulars (0.37, 0.27-0.51) and other ranks were less likely than non-commissioned officers (0.67, 0.46-0.98) to report negative effects of their military career on their children. CONCLUSIONS: Contrary to previous research findings, regulars were more likely to report a negative impact, reflecting this study's focus on the wider military context, rather than just deployment. These findings are consistent with existing research showing links between deployment length and negative impact.

The mental health of the UK Armed Forces in the 21st century: resilience in the face of adversity.

The recent conflicts in Iraq and Afghanistan have attracted considerable political and media interest in the mental health of UK military personnel. As a result of the close operational collaboration between US and UK forces, there have inevitably been many comparisons drawn between the mental health status of the two forces. Considerable research activity suggests that the mental health of UK forces appear to have remained relatively resilient in spite of their considerable exposure to traumatic events; one stark exception to this is the high rates of alcohol misuse which seem to be related to deployment. This paper explores the recently published literature relating to UK military forces and attempts to draw conclusions about the reasons for the apparent resilience shown by the majority of the regular forces.