Level of perceived social support, and associated factors, in combat-exposed (ex-)military personnel: a systematic review and meta-analysis.

PURPOSE: Combat deployment increases exposure to potentially traumatic events. Perceived social support (PSS) may promote health and recovery from combat trauma. This systematic review and meta-analysis aimed to synthesize studies investigating the level of PSS and associated factors among (ex-)military personnel who served in the Iraq/Afghanistan conflicts. METHODS: Five electronic databases were searched in August 2023 and searches were restricted to the beginning of the Iraq/Afghanistan conflicts in 2001. The search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A quality assessment was carried out, and a meta-analysis and narrative synthesis were performed. RESULTS: In total, 35 papers consisting of 19,073 participants were included. Of these, 31 studies were conducted in the United States (US) and 23 were cross-sectional. The pooled mean PSS score was 54.40 (95% CI: 51.78 to 57.01). Samples with probable post-traumatic stress disorder had a lower mean PSS score (44.40, 95% CI: 39.10 to 49.70). Approximately half of the included studies (n = 19) investigated mental health in relation to PSS, whilst only four explored physical health. The most frequently reported risk factors for low PSS included post-traumatic stress disorder, depression and anxiety, whilst post-traumatic growth and unit support were protective factors. CONCLUSION: Higher levels of PSS were generally associated with more positive psychosocial and mental health-related outcomes following deployment. PSS should be targeted in psychosocial interventions and education programmes. Future research should investigate PSS in (ex-)military personnel across other countries and cultures, based on the lack of studies that focused on PSS in countries outside of the US.

Anger Among UK Ex-Service Military Personnel During the COVID-19 Pandemic.

ABSTRACT: Military service and ex-service personnel commonly experience difficulties with anger. The COVID-19 pandemic had several negative consequences upon social, economic, and health factors that influence anger. This study aimed to explore 1) levels of anger in an ex-serving military cohort during the COVID-19 pandemic; 2) self-reported changes in anger compared with prepandemic levels; and 3) identify sociodemographic characteristics, military characteristics, COVID-19 experiences, and COVID-19 stressors associated with anger. UK ex-service personnel ( n = 1499) completed the Dimensions of Anger Reactions 5-item measure within an existing cohort study. Overall, 14.4% reported significant difficulties with anger, and 24.8% reported their anger worsened during the pandemic. Anger was associated with factors such as financial difficulties, extra/new caring responsibilities, and COVID-19 bereavement. Endorsing more COVID-19 stressors was associated with higher odds of anger difficulties. This study highlights the impact of the pandemic on ex-service personnel, including a strain on family/social relationships and financial hardship, which affected anger.

Adjustment disorder in the Armed Forces: a systematic review.

BACKGROUND: In the UK military, adjustment disorder (AjD) is reported as one of the most diagnosed mental disorders, alongside depression, in personnel presenting to mental health services. Despite this, little is understood about what may predict AjD, common treatment or outcomes for this population. AIM: The systematic review aimed to summarise existing research for AjD in Armed Forces (AF) populations, including prevalence and risk factors, and to outline clinical and occupational outcomes. METHOD: A literature search was conducted in December 2020 to identify research that investigated AjD within an AF population (serving or veteran) following the PRISMA guidelines. RESULTS: Eighty-three studies were included in the review. The AjD prevalence estimates in AF populations with a mental disorder was considerably higher for serving AF personnel (34.9%) compared to veterans (12.8%). Childhood adversities were identified as a risk factor for AjD. AjD was found to increase the risk of suicidal ideation, with one study reporting a risk ratio of 4.70 (95% Confidence Interval: 3.50-6.20). Talking therapies were the most common treatment for AjD, however none reported on treatment effectiveness. CONCLUSION: This review found that AjD was commonly reported across international AF. Despite heterogeneity in the results, the review identifies several literature gaps.

Cost of post-deployment screening for mental illness in the UK military: findings from a cluster randomised controlled trial.

BACKGROUND: Little is known about the economic impact of military mental health screening. AIMS: To investigate (a) whether post-deployment screening of military personnel affects use and cost of services and (b) the impact of psychiatric morbidity on costs. METHODS: Participants were recruited from UK Royal Marine and Army platoons and randomised to an intervention group (which received tailored advice predicated upon mental health status) or a control group (which received general advice following assessment of mental health status). The intervention costs were calculated while service use and associated costs were assessed at 12-month follow-up. RESULTS: Data were available for 6323 participants. Mean screening cost was £34. Service costs were slightly higher in the control group compared to the intervention group (£1197 vs. £1147) which was not statistically significant (bootstrapped 95%CI, -£363 to £434. In both groups, screening and control, costs were significantly higher for those who screened positive for mental health problems. CONCLUSIONS: Costs were not affected by screening. In countries that have already implemented post-deployment screening, the political cost of disinvestment needs careful consideration. Those who develop psychiatric morbidity have substantially higher care costs than those who do not.

Risk and protective factors for offending among UK Armed Forces personnel after they leave service: a data linkage study.

BACKGROUND: A proportion of ex-military personnel who develop mental health and social problems end up in the Criminal Justice System. A government review called for better understanding of pathways to offending among ex-military personnel to improve services and reduce reoffending. We utilised data linkage with criminal records to examine the patterns of offending among military personnel after they leave service and the associated risk (including mental health and alcohol problems) and socio-economic protective factors. METHOD: Questionnaire data from a cohort study of 13 856 randomly selected UK military personnel were linked with national criminal records to examine changes in the rates of offending after leaving service. RESULTS: All types of offending increased after leaving service, with violent offending being the most prevalent. Offending was predicted by mental health and alcohol problems: probable PTSD, symptoms of common mental disorder and aggressive behaviour (verbal, property and threatened or actual physical aggression). Reduced risk of offending was associated with post-service socio-economic factors: absence of debt, stable housing and relationship satisfaction. These factors were associated with a reduced risk of offending in the presence of mental health risk factors. CONCLUSIONS: Ex-military personnel are more likely to commit violent offences after leaving service than other offence-types. Mental health and alcohol problems are associated with increased risk of post-service offending, and socio-economic stability is associated with reduced risk of offending among military veterans with these problems. Efforts to reduce post-service offending should encompass management of socio-economic risk factors as well as mental health.

Contribution of mental ill health during military service to postservice benefit claims in the UK.

OBJECTIVES: While most UK military personnel transition successfully into civilian life, some experience unemployment and disability, which may be partly attributable to in-service factors. This study aims to determine the degree to which in-service mental health problems impact on postservice benefit claims. METHODS: Using data from a cohort of 5598 recent leavers from regular service in the UK Armed Forces linked with data from the Department for Work and Pensions, we assessed associations between in-service mental health and postservice benefit claims, and the population attributable fraction (PAF) of benefit claims related to in-service mental health. An analysis with postservice mental ill health as mediator was performed to determine the degree to which the observed effects were a consequence of persistent illness, as opposed to remitted. RESULTS: Mental illness occurring in-service predicted both unemployment and disability claims, partly mediated by postservice health (23%-52% total effects mediated), but alcohol misuse did not. Common mental disorder (CMD) (PAF 0.07, 95% CI: 0.02 to 0.11) and probable post-traumatic stress disorder (PTSD) (PAF 0.05, 95% CI 0.01 to 0.09) contributed to unemployment claims. Probable PTSD was the largest contributor to disability claims (PAF 0.25, 95% CI 0.13 to 0.36), with a smaller contribution from CMD (PAF 0.16, 95% CI 0.03 to 0.27). CONCLUSIONS: In-service mental ill health gives rise to benefit claims. These effects are only partly mediated by postservice mental health, implying that in-service (or pre-service) mental issues have carry-over effects into civilian life even if remitted. Better prevention and treatment of in-service PTSD symptoms may well reduce postservice disability claims.

The symptomatology of psychological trauma in the aftermath of war (1945-1980): UK army veterans, civilians and emergency responders.

BACKGROUND: UK veterans suffering from a psychological or psychiatric illness as a consequence of service in the Second World War were entitled to a war pension. Their case files, which include regular medical assessments, are a valuable resource to investigate the nature, distribution and duration of symptoms. METHODS: A standardised form was used to collect data from pension records of a random sample of 500 UK army veterans from the first presentation in the 1940s until 1980. Data were also gathered from 50 civilians and 54 emergency responders with a pension for post-traumatic illness following air-raids. RESULTS: The 10 most common symptoms reported by veterans were anxiety, depression, sleep problems, headache, irritability/anger, tremor/shaking, difficulty completing tasks, poor concentration, repeated fears and avoidance of social contact. Nine of the 10 were widely distributed across the veteran population when symptoms were ranked by the number of subjects who reported them. Nine symptoms persisted significantly longer in the veteran sample than in emergency responders. These included seven of the most common symptoms, together with two others: muscle pain and restlessness. The persistence of these symptoms in the veteran group suggests a post-traumatic illness linked to lengthy overseas service in combat units. CONCLUSIONS: The nature and duration of symptoms exhibited by veterans may be associated with their experience of heightened risks. Exposure to severe or prolonged trauma seems to be associated with chronic multi-symptom illness, symptoms of post-traumatic stress and somatic expressions of pain that may delay or complicate the recovery process.

Unemployment and benefit claims by UK veterans in the new millennium: results from a record linkage study.

OBJECTIVES: In the first study of its kind in the UK, we linked pensions data on benefit claims with data from the King's Military Cohort to assess uptake of unemployment and disability benefits in military veterans of the UK Armed Forces. METHODS: Benefits data were matched with data on the mental health, demographics and military-related variables for 7942 veterans who had previously served as regulars and transitioned to civilian life between 2003 and 2016. Associations between demographic and service-related factors and benefit claims were assessed using Cox regression to take into account period at risk. RESULTS: Around 20% of veterans claim unemployment benefits (UB) shortly after leaving, but this proportion drops rapidly to around 2% in the first 2 years post service. Receipt of disability benefits (DB) is less common (1.5%), but longer-term. The most consistent predictors of postservice benefit usage were: low rank (a proxy for socio-economic status while in service) (HR 1.42 (95% CI 1.23 to 1.65) for UB and 1.59 (95% CI 1.11 to 2.27) for DB); leaving service (HR 1.29 (95% CI 1.07 to 1.56) between unplanned leaving and UB, and 7.51 (95% CI 5.31 to 10.6) between medical discharge and DB), and having a history of claiming benefits before joining the Services (HR 1.62 (95% CI 1.34 to 1.95) between preservice and postservice UB, and 2.86 (95% CI 1.09 to 7.47) between preservice and postservice DB). CONCLUSIONS: Benefit claims by veterans are largely driven by socioeconomic, rather than military, factors. Additional employment-focused support to Service leavers may be particularly useful to lower-ranked personnel and those leaving in an unplanned way. Continuity of care and medical oversight is a key concern for those with medical discharges.

Resilience-based intervention for UK military recruits: a randomised controlled trial.

OBJECTIVES: We evaluated a military resilience intervention which aimed to help UK military recruits to manage their personal health and well-being more effectively. METHODS: Trainers within six pre-existing training teams were randomly allocated by team to deliver a resilience-based intervention (SPEAR) or usual training (control) during recruit training. 23 trainers delivered SPEAR; 18 delivered the control training. 707 recruits participated (n=358 SPEAR and n=349 controls). Outcome measures were obtained before and after recruit training and 3 months later. Measures of post-traumatic stress disorder (PTSD), common mental disorder (CMD) symptoms, alcohol use, homesickness and mental health stigmatisation were obtained at baseline. Repeat baseline scales plus measures of help-seeking, cohesion, leadership and training impact were obtained at the two follow-up points. RESULTS: Response rates were 91.7% (baseline), 98.1% (post) and 73.6% (follow-up). Following adjustment for potential confounders, levels of PTSD, CMD symptoms, alcohol misuse, help-seeking and homesickness were not significantly different between groups at any measurement point. Stigmatisation was significantly lower among SPEAR recipients at baseline but was not significantly different at the two follow-up points. Following adjustment for mental health confounders, there were no significant between-group differences in perceptions of leadership and cohesion and in ratings of six training outcomes at the two follow-up points. CONCLUSIONS: We found no evidence that resilience-based training had any specific benefit to the health and well-being of UK military recruits.

Post-deployment screening for mental disorders and tailored advice about help-seeking in the UK military: a cluster randomised controlled trial.

BACKGROUND: The effectiveness of post-deployment screening for mental disorders has not been assessed in a randomised controlled trial. We aimed to assess whether post-deployment screening for post-traumatic stress disorder (PTSD), depression, anxiety, or alcohol misuse was effective. We defined screening as the presumptive identification of a previously unrecognised disorder using tests to distinguish those who probably had the disorder from those who probably did not so that those people with a probable disorder could be referred appropriately, and assessed effectiveness and consequences for help-seeking by the odds ratio at follow-up between those receiving tailored help-seeking advice and those who received general mental health advice. METHODS: We did a cluster randomised controlled trial among Royal Marines and Army personnel in the UK military after deployment to Afghanistan. Platoons were randomly assigned (1:1 initially, then 2:1) by stratified block randomisation with randomly varying block sizes of two and four to the screening group, which received tailored help-seeking advice, or the control group, which received general mental health advice. Initial assessment took place 6-12 weeks after deployment; follow-up assessments were done 10-24 months later. Follow-up measures were the PTSD Checklist-Civilian Version, Patient Health Questionnaire-9, Generalised Anxiety Disorder-7 scale, Alcohol Use Disorder Identification Test (AUDIT), and self-reported help-seeking from clinical and welfare providers comparing those receiving tailored advice and those receiving only general advice. All participants and all investigators other than the person who analysed the data were masked to allocation. The primary outcomes were PTSD, depression or generalised anxiety disorder, and alcohol misuse at follow-up. A key secondary outcome was assessment of whether post-deployment screening followed by tailored advice would modify help-seeking behaviour. Comparisons were made between screening and control groups, with primary analyses by intention to treat. This trial is registered with the ISRCTN Registry, number ISRCTN19965528. FINDINGS: Between Oct 24, 2011, and Oct 31, 2014, 434 platoons comprising 10 190 personnel were included: 274 (6350 personnel) in the screening group and 160 (3840 personnel) in the control group. 5577 (88%) of 6350 personnel received screening and 3996 (63%) completed follow-up, whereas 3149 (82%) of 3840 received the control questionnaire and 2369 (62%) completed follow-up. 1958 (35%) of 5577 personnel in the screening group declined to see the tailored advice, but those with PTSD (83%) or anxiety or depression (84%) were more likely than non-cases (64%) to view the advice (both p<0·0001). At follow-up, there were no significant differences in prevalence between groups for PTSD (adjusted odds ratio 0·92, 95% CI 0·75-1·14), depression or anxiety (0·91, 0·71-1·16), alcohol misuse (0·88, 0·73-1·06), or seeking support for mental disorders (0·92, 0·78-1·08). INTERPRETATION: Post-deployment screening for mental disorders based on tailored advice was not effective at reducing prevalence of mental health disorders nor did it increase help-seeking. Countries that have implemented post-deployment screening programmes for mental disorders should consider monitoring the outcomes of their programmes. FUNDING: The US Army Medical Research and Materiel Command-Military Operational Medicine Research Program (USAMRMC-MOMRP).