Holding and rupture: Describing post-traumatic stress among former UK Army and Royal Marine personnel deployed to Iraq and Afghanistan.

Former UK military personnel who were previously deployed to Iraq and Afghanistan in combat roles have exhibited elevated levels of Post-Traumatic Stress Disorder (PTSD) compared to other groups. The present qualitative analyses used semi-structured interviews and a framework analysis to compare the experiences of symptomatic (N=10) and asymptomatic (N=7) former Army and Royal Marine personnel who were exposed to combat. Participants were drawn from a large UK military health and wellbeing cohort study and were sampled based upon probable PTSD status using scores from the PTSD Checklist-Civilian Version (PCL-C). All symptomatic participants attributed the development of post-traumatic stress to deployment events, with one additionally ascribing symptoms to childhood events. Among the participants, post-traumatic stress was temporarily buffered, and held at bay, by the holding function of various military structures, including the military collective; cultural and ethical frameworks that helped to organise traumatic experiences; an operational necessity for psychological compartmentalisation and even the distraction of deployment itself. Leaving the military appeared to elicit a global rupture of these supports. As a result, the military-to-civilian transition led to an intensification of post-traumatic stress, including deployment-related memories, among the symptomatic participants. In contrast, asymptomatic participants tended to report continuity of their holding structures across the lifespan, especially across the military-to-civilian transition. The onset and maintenance of post-traumatic stress may thus be explained by an interplay between the capacity of holding structures and the magnitude of lifetime rupture. Overall, findings might provide an explanation for the widening discrepancies between those with enduring post-traumatic stress and those without and further research is required to determine the fit of our findings for other groups and contexts. This approach further illustrates the need to situate individual experiences of post-traumatic stress in wider structural, ecological, cultural and ethical contexts.

Enhanced Skills Training in Affective and Interpersonal Regulation versus Treatment as Usual for ICD-11 Complex PTSD: A Pilot Randomised Controlled Trial (The RESTORE Trial).

INTRODUCTION: Complex PTSD (CPTSD) is a relatively new condition in ICD-11. This pilot randomised controlled trial aimed to compare a four-module intervention developed to target all symptoms of ICD-11 CPTSD, namely Enhanced Skills in Affective and Interpersonal Regulation (ESTAIR) with treatment as usual (TAU). The purpose of the study was to assess feasibility, safety, acceptability, and preliminary outcomes at the end of treatment and 3-month follow-up. METHODS: A total of N = 56 eligible veterans with CPTSD were randomised to either ESTAIR (n = 28) or TAU (n = 28). Linear mixed models were conducted to assess CPTSD severity, the primary outcome, as measured by the International Trauma Questionnaire (ITQ). RESULTS: Treatment dropout in ESTAIR and TAU was low and equivalent (18% vs. 11%; χ2 (1) = 1.19, p = 0.275), and study retention was high, supporting the feasibility of the study. No serious adverse effects and very few adverse effects occurred, none of which were deemed related to the study. ESTAIR provided significantly greater reduction in CPTSD severity across time for ITQ PTSD (p < 0.001) and DSO (p < 0.001) symptoms. CPTSD pre-to-post effect sizes for ESTAIR were large (PTSD d = 1.78; DSO d = 2.00). Remission of probable CPTSD diagnosis at post-treatment was substantially greater in ESTAIR compared to TAU with only 13.6% versus 84% (p < 0.001) retaining the diagnosis. CONCLUSION: A trial of ESTAIR versus TAU for the treatment of ICD-11 CPTSD indicates the potential efficacy of ESTAIR as well as its feasibility, safety, and acceptability.

Pathways to mental health care in active military populations across the Five-Eyes nations: An integrated perspective.

Military service is associated with increased risk of mental health problems. Previous reviews have pointed to under-utilization of mental health services in military populations. Building on the most recent systematic review, our narrative, critical review takes a complementary approach and considers research across the Five-Eyes nations from the past six years to update and broaden the discussion on pathways to mental healthcare in military populations. We find that at a broad population level, there is improvement in several indicators of mental health care access, with greater gains in initial engagement, time to first treatment contact, and subjective satisfaction with care, and smaller gains in objective indicators of adequacy of care. Among individual-level barriers to care-seeking, there is progress in improving recognition of need for care and reducing stigma concerns. Among organizational-level barriers, there are advances in availability of services and cultural acceptance of care-seeking. Other barriers, such as concerns around confidentiality, career impact, and deployability persist, however, and may account for some remaining unmet need. To address these barriers, new initiatives that are more evidence-based, theoretically-driven, and culturally-sensitive, are therefore needed, and must be rigorously evaluated to ensure they bring about additional improvements in pathways to care.

ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) in treatment seeking veterans: risk factors and comorbidity.

PURPOSE: Emerging evidence suggests that ICD-11 CPTSD is a more common condition than PTSD in treatment seeking samples although no study has explored risk factors and comorbidities of PTSD and CPTSD in veteran populations. In this study, risk factors and comorbidity between veterans meeting criteria for PTSD or CPTSD using the ICD-11 International Trauma Questionnaire (ITQ) were explored. METHODS: A sample of help-seeking veterans who had been diagnosed with a mental health difficulty (n = 177) was recruited. Participants completed a range of mental health and functioning measures. Multinomial logistic regression analysis was conducted to explore differences in the above factors between participants meeting case criteria for PTSD, CPTSD or another mental health disorder. RESULTS: Those with CPTSD appeared to have taken longer to seek help, reported higher rates of childhood adversity and more experiences of emotional or physical bullying during their military careers. Further, participants with CPTSD reported a greater burden of comorbid mental health difficulties including high levels of dissociation, anger, difficulties related to moral injury and common mental health difficulties and greater degree of impairment including social isolation, sleep difficulties and impaired functioning. CONCLUSIONS: Considering that CPTSD is a more debilitating condition than PTSD, there is now an urgent need to test the effectiveness of new and existing interventions in veterans with CPTSD.

Malta's only acute public hospital service during COVID-19: a diary of events from the first wave to transition phase.

INTRODUCTION: COVID-19 has challenged healthcare systems worldwide. Some countries collapsed under surge conditions, while others (such as Malta) showed resilience. Public health measures in Malta quickly reined in COVID-19 spread. This review summarizes pandemic preparedness measures in Malta and the impact on routine services. METHODS: A literature search was conducted using Google, Google Scholar and PubMed and by reviewing Maltese online newspapers. A comprehensive summary of internal operations conducted at Mater Dei Hospital (MDH) was made available. RESULTS: A hospital 'Incident Command Group' was set up to plan an optimal COVID-19 response strategy. A 'rapid response team' was also created to cater for the logistics and management of supplies. A 'COVID-19 Emergency Operation Centre' simulated different COVID-19 scenarios. All elective services were suspended and all staff were mandatorily trained in wearing personal protective equipment. Staff were also retrained in the care of COVID-19 patients. In preparation for potential admission surges, MDH underwent rapid expansion of normal and intensive care beds. Swabbing was ramped up to one of the highest national rates worldwide. The cost for hospital COVID-19 preparedness exceeded €100 million for Malta's half a million population. CONCLUSION: Malta and its sole acute hospital coped well with the first wave with 680 cases and 9 deaths. The increased ability to deal with COVID-19 (a principally respiratory pathogen) will serve well for the anticipated combined annual influenza and the COVID-19 second wave this coming winter.

An Open Label Pilot Study of a Brief Psychosocial Intervention for Disaster and Trauma Survivors.

BACKGROUND: In the aftermath of disaster, a large proportion of people will develop psychosocial difficulties that impair recovery, but for which presentations do not meet threshold criteria for disorder. Although these adjustment problems can cause high distress and impairment, and often have a trajectory towards mental health disorder, few evidence-based interventions are available to facilitate recovery. OBJECTIVE: This paper describes the development and pilot testing of an internationally developed, brief, and scalable psychosocial intervention that targets distress and poor adjustment following disaster and trauma. METHOD: The Skills fOr Life Adjustment and Resilience (SOLAR) program was developed by an international collaboration of trauma and disaster mental health experts through an iterative expert consensus process. The resulting five session, skills-based intervention, deliverable by community-based or frontline health or disaster workers with little or no formal mental health training (known as coaches), was piloted with 15 Australian bushfire survivors using a pre-post with follow up, mixed-methods design study. RESULTS: Findings from this pilot demonstrated that the SOLAR program was safe and feasible for non-mental health frontline workers (coaches) to deliver locally after two days of training. Participants' attendance rates and feedback about the program indicated that the program was acceptable. Pre-post quantitative analysis demonstrated reductions in psychological distress, posttraumatic stress symptoms, and impairment. CONCLUSIONS: This study provides preliminary evidence that the delivery of the SOLAR program after disaster by trained, frontline workers with little or no mental health experience is feasible, acceptable, safe, and beneficial in reducing psychological symptoms and impairment among disaster survivors. Randomized controlled trials of the SOLAR program are required to advance evidence of its efficacy.

A validation study of the International Trauma Questionnaire to assess post-traumatic stress disorder in treatment-seeking veterans.

BACKGROUND: Veterans with post-traumatic stress disorder (PTSD) typically report a poorer treatment response than those who have not served in the Armed Forces. A possible explanation is that veterans often present with complex symptoms of PTSD. ICD-11 PTSD and complex PTSD (CPTSD) have not previously been explored in a military sample. AIMS: This study aimed to validate the only measure of ICD-11 PTSD and CPTSD, the International Trauma Questionnaire, and assess the rates of the disorder in a sample of treatment-seeking UK veterans. METHOD: A sample of help-seeking veterans (N = 177) was recruited from a national charity in the UK that provides clinical services to veterans. Participants completed measures of ICD-11 PTSD and CPTSD as well as childhood and adult traumatic life events. Confirmatory factor analysis was used to assess the latent structure of PTSD and CPTSD symptoms, and rates of the disorders were estimated. RESULTS: The majority of the participants (70.7%) reported symptoms consistent with a diagnosis of either PTSD or CPTSD. Results indicated the presence of two separate disorders, with CPTSD being more frequently endorsed (56.7%) than PTSD (14.0%). CPTSD was more strongly associated with childhood trauma than PTSD. CONCLUSIONS: The International Trauma Questionnaire can adequately distinguish between PTSD and CPTSD within clinical samples of veterans. There is a need to explore the effectiveness of existing and new treatments for CPTSD in military personnel.

Neuropsychiatric Outcomes in UK Military Veterans With Mild Traumatic Brain Injury and Vestibular Dysfunction.

OBJECTIVE: To estimate the frequency of vestibular dysfunction following blunt, blast, and combined blunt and blast mild traumatic brain injury (mTBI) and thereon assess the long-term impact of vestibular dysfunction on neurobehavioral function and disability independently of comorbid psychiatric symptoms. SETTING: Combat Stress residential and Veterans' Outreach drop-in centers for psychological support. PARTICIPANTS: One hundred sixty-two help-seeking UK military veterans. MAIN MEASURES: Self-reported frequency and severity of mTBI (using the Ohio State TBI Identification Method), Vertigo Symptom Scale, PTSD Checklist for DSM-5, Kessler Psychological Distress Scale (K10), Neurobehavioral Symptom Inventory, Headache Impact Test (HIT6), Memory Complaints Inventory, World Health Organization Disability Assessment Schedule II short version (WHODAS 2.0). RESULTS: Seventy-two percent of the sample reported 1 or more mTBIs over their lifetime. Chi-square analyses indicated that vestibular disturbance, which affected 69% of participants, was equally prevalent following blunt (59%) or blast (47%) injury and most prevalent following blunt and blast combined (83%). Mediation analysis indicated that when posttraumatic stress disorder, depression, and anxiety were taken into account, vestibular dysfunction in participants with mTBI was directly and independently associated with increased postconcussive symptoms and functional disability. CONCLUSION: Vestibular dysfunction is common after combined blunt and blast mTBI and singularly predictive of poor long-term mental health. From a treatment perspective, vestibular rehabilitation may provide relief from postconcussive symptoms other than dizziness and imbalance.

Treatment of military-related post-traumatic stress disorder: challenges, innovations, and the way forward.

Post-traumatic stress disorder (PTSD) is one of the common mental disorders in military and veteran populations. Considerable research and clinical opinion has been focused on understanding the relationship between PTSD and military service and the implications for prevention, treatment, and management. This paper examines factors associated with the development of PTSD in this population, considers issues relating to engagement in treatment, and discusses the empirical support for best practice evidence-based treatment. The paper goes on to explore the challenges in those areas, with particular reference to treatment engagement and barriers to care, as well as treatment non-response. The final section addresses innovative solutions to these challenges through improvements in agreed terminology and definitions, strategies to increase engagement, early identification approaches, understanding predictors of treatment outcome, and innovations in treatment. Treatment innovations include enhancing existing treatments, emerging non-trauma-focused interventions, novel pharmacotherapy, personalized medicine approaches, advancing functional outcomes, family intervention and support, and attention to physical health.

Describing the profile of a population of UK veterans seeking support for mental health difficulties.

Background: Evidence suggests that veterans with mental health issues have poorer treatment outcomes than civilian counterparts. Understanding the difficulties faced by veterans could help focus treatments and improve outcomes.Aims: To survey a representative sample of treatment-seeking veterans to explore their mental health needs.Methods: A random sample of UK veterans who had engaged with a national mental health charity in the UK was drawn. Individuals completed questionnaires about their health, military experiences and pre-enlistment vulnerabilities.Results: Four hundred and three out of six hundred (67.2%) participants returned completed questionnaires. PTSD was the most commonly endorsed mental health difficulty (82%), followed by problems with anger (74%), common mental health difficulties (72%) and alcohol misuse (43%). Comorbidity was frequent; with 32% of those with PTSD meeting criteria for three other health outcomes versus only 5% with PTSD alone.Conclusions: Results indicate the complexity of presentations within treatment seeking veterans. These difficulties may partly explain the poorer treatment outcomes reported in veterans in comparison to the general public. As such, it would be prudent for interventions targeted at veterans with mental health difficulties to attempt to address the range of issues faced by this population rather than focus on a particular presenting problem.

Bivalirudin as an Alternative Anticoagulant for Cardiopulmonary Bypass During Adult Cardiac Surgery-A Change in Practice.

The referral of patients for open heart surgery, presenting with a history of heparin hypersensitivity instigated a multidisciplinary effort to find an alternative anticoagulant to heparin. The various options mentioned in the literature call for changes in the routine practice of open heart surgery on cardiopulmonary bypass. These changes involve mostly the perfusion setup and conduct on bypass and to a lesser extent the anesthetic and surgical practice. Nevertheless, the different professions involved in the cardiac surgical firm discussed the proposed changes in a multidisciplinary effort. A new protocol was drafted, endorsed, and executed. The authors highlight these changes and their successful use in the subsequent case study.

Exploring optimum cut-off scores to screen for probable posttraumatic stress disorder within a sample of UK treatment-seeking veterans.

Background: Previous research exploring the psychometric properties of the scores of measures of posttraumatic stress disorder (PTSD) suggests there is variation in their functioning depending on the target population. To date, there has been little study of these properties within UK veteran populations. Objective: This study aimed to determine optimally efficient cut-off values for the Impact of Event Scale-Revised (IES-R) and the PTSD Checklist for DSM-5 (PCL-5) that can be used to assess for differential diagnosis of presumptive PTSD. Methods: Data from a sample of 242 UK veterans assessed for mental health difficulties were analysed. The criterion-related validity of the PCL-5 and IES-R were evaluated against the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Kappa statistics were used to assess the level of agreement between the DSM-IV and DSM-5 classification systems. Results: The optimal cut-off scores observed within this sample were 34 or above on the PCL-5 and 46 or above on the IES-R. The PCL-5 cut-off is similar to the previously reported values, but the IES-R cut-off identified in this study is higher than has previously been recommended. Overall, a moderate level of agreement was found between participants screened positive using the DSM-IV and DSM-5 classification systems of PTSD. Conclusions: Our findings suggest that the PCL-5 and IES-R can be used as brief measures within veteran populations presenting at secondary care to assess for PTSD. The use of a higher cut-off for the IES-R may be helpful for differentiating between veterans who present with PTSD and those who may have some sy`mptoms of PTSD but are sub-threshold for meeting a diagnosis. Further, the use of more accurate optimal cut-offs may aid clinicians to better monitor changes in PTSD symptoms during and after treatment.

Planteamiento: La investigación previa que exploró las propiedades psicométricas de las puntuaciones de las medidas del trastorno de estrés postraumático (TEPT) sugiere que existe una variación en su funcionamiento según la población objetivo. Hasta la fecha, ha habido pocos estudios sobre estas propiedades dentro de las poblaciones de veteranos del Reino Unido. Objetivo: Este estudio tuvo como objetivo determinar valores de corte óptimamente eficientes para la escala revisada del impacto de los eventos (IES-R, siglas en inglés de Impact of Event Scale-Revised) y la lista de TEPT para el DSM-5 (PCL-5, siglas en inglés de PTSD Checklist for DSM-5) que pueden utilizarse para evaluar el diagnóstico diferencial de TEPT presuntivo. Métodos: Se analizaron los datos de una muestra de 242 veteranos del Reino Unido evaluados por dificultades de salud mental. La validez relacionada con los criterios del PCL-5 y la IES-R se evaluó frente a la Escala de TEPT administrada por el clínico para el DSM-5 (CAPS-5, siglas en inglés de Clinician-Administered PTSD Scale for DSM-5). Se usaron estadísticas Kappa para evaluar el nivel de acuerdo entre los sistemas de clasificación del DSM-IV y DSM-5. Resultados: Las puntuaciones de corte óptimos observadas dentro de esta muestra fueron de 34 o más en la PCL-5 y de 46 o más en la IES-R. El límite de la PCL-5 es similar a los valores informados anteriormente, pero el punto de corte IES-R identificado en este estudio es más alto de lo que se había recomendado anteriormente. En general, se encontró un nivel moderado de acuerdo entre los participantes seleccionados con los sistemas de clasificación DSM-IV y DSM-5 para el TEPT. Conclusiones: Nuestros hallazgos sugieren que la PCL-5 y la IES-R pueden usarse como medidas breves en poblaciones de veteranos que se presentan en el sistema sanitario secundario para evaluar el TEPT. El uso de un punto de corte más alto para la IES-R puede ser útil para diferenciar entre los veteranos que presentan TEPT y aquellos que pueden presentar algunos síntomas de TEPT, pero que están por debajo del umbral y no cumplen con el diagnóstico. Además, el uso de puntos de corte óptimos más precisos puede ayudar a los clínios a controlar mejor los cambios en los síntomas de TEPT durante y después del tratamiento.

Do Alcohol Misuse, Service Utilisation, and Demographic Characteristics Differ between UK Veterans and Members of the General Public Attending an NHS General Hospital?

The aim of this paper was to provide insights into alcohol misuse within UK veterans to inform as to whether their presentations differ from the general public. This was done by exploring differences in the severity of alcohol misuse between UK veterans and the general public admitted to a general NHS hospital over an 18 month period using retrospective data. All patients admitted to the hospital were screened for alcohol misuse. Those deemed as experiencing problems were referred for specialist nurse-led support. A total of 2331 individuals were referred for this supported and administered with a standardised assessment that included measures of the severity of alcohol difficulties (AUDIT), dependency levels (LDQ), and assessed for the presence of withdrawal symptoms (CIWA-Ar). In addition, information was collected on service utilisation, referral category (medical or mental health), other substance misuse, and demographic characteristics. No differences were found between the severity of reported alcohol difficulties between veterans and non-veterans. Evidence was found to suggest that veterans were more likely to be referred for support with alcohol difficulties at an older age and to be admitted to hospital for longer periods of time. This could have considerable cost implications for the NHS. It was more common for veterans to present at hospital with physical health difficulties prior to being referred for support for alcohol.

Long-term responses to treatment in UK veterans with military-related PTSD: an observational study.

OBJECTIVES: Military-related trauma can be difficult to treat. Evaluating longer term responses to treatment and identifying which individuals may need additional support could inform clinical practice. We assessed 1-year outcomes in UK veterans treated for post-traumatic stress disorder (PTSD). DESIGN: Within-participant design. SETTING: The intervention was offered by Combat Stress, a mental health charity for veterans in the UK. PARTICIPANTS: The sample included 401 veterans who completed a standardised 6-week residential treatment. Of these, 268 (67%) were successfully followed up a year after the end of treatment. METHODS: A range of health outcomes were collected pretreatment and repeated at standard intervals post-treatment. The primary outcome was severity of PTSD symptoms, and secondary outcomes included measures of other mental health difficulties (depression, anxiety and anger), problems with alcohol, and social and occupational functioning. RESULTS: Significant reductions in PTSD severity were observed a year after treatment (PSS-I: -11.9, 95% CI -13.1 to -10.7). Reductions in the secondary outcomes were also reported. Higher levels of post-treatment functional impairment (0.24, 95% CI 0.08 to 0.41) and alcohol problems (0.18, 95% CI 0.03 to 0.32) were associated with poorer PTSD treatment response at 12 months. CONCLUSIONS: This uncontrolled study suggests the longer term benefits of a structured programme to treat UK veterans with PTSD. Our findings point to the importance of continued support targeted for particular individuals post-treatment to improve longer term outcomes.

Mental Health Difficulties and Help-Seeking Beliefs within a Sample of Female Partners of UK Veterans Diagnosed with Post-Traumatic Stress Disorder.

In the UK there is a paucity of research about the needs of partners who are supporting ex-service personnel with mental health difficulties. In this study, we surveyed the mental health needs and barriers to help-seeking within a sample of partners of UK veterans who had been diagnosed with PTSD. Our sample included 100 participants. Forty-five percent met criteria for alcohol problems, 39% for depression, 37% for generalised anxiety disorder and 17% for symptoms of probable PTSD. Participants who met case criteria for depression, anxiety and problems with alcohol were more likely to report a greater number of help-seeking barriers. Participants who were experiencing mental health difficulties were more likely to endorse barriers connected to stigmatising beliefs than those associated with practical issues around accessing mental health services. The evidence presented suggests there may be a considerable burden of mental illness within this population. It would seem prudent to conduct further work to understand how best to address this clinical need.

Squamous cell carcinoma of unknown origin metastasising to the right atrium causing acute heart failure.

We describe a case of metastasis to the heart, which was initially suspected to be a myxoma, causing acute right heart failure. Emergency surgery was carried out by opening the right atrium and superior vena cava, and debulking the tumour in a piecemeal fashion, providing temporary relief of symptoms. The histology showed this to be metastatic squamous cell carcinoma possibly of head and neck origin. This is extremely rare, with few published cases. Full endoscopic and CT, including positron emission tomography CT, investigation of the head and neck was performed with no primary findings. Only two such cases of squamous cell carcinoma of unknown origin metastasising to the heart have been described, and, in both cases, the patients died within several weeks of diagnosis. This patient remains alive 2 months postoperatively and is receiving radiotherapy to the chest, but his prognosis remains poor.

Mental health and functional impairment outcomes following a 6-week intensive treatment programme for UK military veterans with post-traumatic stress disorder (PTSD): a naturalistic study to explore dropout and health outcomes at follow-up.

OBJECTIVE: Combat Stress, a UK national charity for veterans with mental health problems, has been funded by the National Health Service (NHS) to provide a national specialist service to deliver treatment for post-traumatic stress disorder (PTSD). This paper reports the efficacy of a PTSD treatment programme for UK veterans at 6 months follow-up. DESIGN: A within subject design. SETTING: UK veterans with a diagnosis of PTSD who accessed Combat Stress. PARTICIPANTS: 246 veterans who received treatment between late 2012 and early 2014. INTERVENTION: An intensive 6-week residential treatment programme, consisting of a mixture of individual and group sessions. Participants were offered a minimum of 15 individual trauma-focused cognitive behavioural therapy sessions. In addition, participants were offered 55 group sessions focusing on psychoeducational material and emotional regulation. MAIN OUTCOME MEASURES: Clinicians completed measures of PTSD and functional impairment and participants completed measures of PTSD, depression, anger and functional impairment. RESULTS: We observed significant reductions in PTSD scores following treatment on both clinician completed measures (PSS-I: -13.0, 95% CI -14.5 to -11.5) and self-reported measures (Revised Impact of Events Scale (IES-R): -16.5, 95% CI -19.0 to -14.0). Significant improvements in functional impairment were also observed (eg, Health of the Nation Outcome Scales (HONOS): -6.85, 95% CI -7.98 to -5.72). There were no differences in baseline outcomes between those who completed and those who did not complete the programme, or post-treatment outcomes between those we were able to follow-up at 6 months and those lost to follow-up. CONCLUSIONS: In a naturalistic study we observed a significant reduction in PTSD scores and functional impairment following treatment. These improvements were maintained at 6 month follow-up. Our findings suggest it may be helpful to take a closer look at combining individual trauma-focused cognitive behaviour therapy and group sessions when treating veterans with PTSD. This is the first UK study of its kind, but requires further evaluation.

PTSD, stigma and barriers to help-seeking within the UK Armed Forces.

Among the general public, much is known about the longer-term consequences of not seeking support for mental health difficulties. However, within military populations, and in particular, the UK Armed Forces, less is known. Understanding the factors that present barriers for UK service personnel with mental health difficulties accessing support is important because this may provide a means for support personnel to seek help sooner. This paper explores the literature relating to the impact of untreated post-traumatic stress disorder (PTSD) among military personnel, attempts to draw conclusions about the barriers that may prevent personnel seeking help and the efficacy of previous interventions to address these. Stigma has been highlighted as the key barrier to help-seeking behaviours, in particular, internal stigma, which can be classified as negative beliefs about the self that an individual may hold as a result of experiencing symptoms of PTSD.

Presentations and management of Post Traumatic Stress Disorder and the elderly: a need for investigation.

BACKGROUND: With an aging population increasing presentations of cases of Post Traumatic Stress Disorder (PTSD) can be expected to old age services. While progress has been made in recent years in relation to the understanding and development of aetiological theories, classification, assessment and management strategies and protocols in the adult population, similar advances have lagged behind for the elderly. AIMS: To review the adult literature regarding PTSD and discuss how this might apply to an elderly population. An attempt is made to highlight a better awareness of the field of psychological trauma in the elderly in the hope of stimulating debate and research. METHOD: A review of the adult literature is conducted relating to classification, aetiology, demographic features, vulnerability, assessment, clinical management including psychotherapy and medications and how these may apply to the elderly. RESULTS: Little has been published in this field that directly relates to the elderly. The adult literature allows insight into understanding how PTSD may present in the elderly, and how they may be managed. CONCLUSIONS: Further specific research is needed in the elderly in order to facilitate a better understanding of PTSD that present in this unique population. This will lead to better clinical assessment, management and treatment provision.