Mental health, ethnicity and the UK armed forces: Historical lessons for research and policy.

BACKGROUND: UK armed forces have recruited from other races and ethnicities at times of crisis. To meet diversity targets, they have also recruited indigenous groups of non-White British heritage. Considered at greater risk of mental health problems generally, these populations are likely to suffer more in combat and in transition to civilian life. Yet, there is little data on how they fare. METHODS: A scoping review was conducted of peer-reviewed studies of psychological illnesses suffered by racial and ethnic minority soldiers from World War One to the present, together with research at the National Archives, Wellcome Trust Archives and the Imperial War Museum for unpublished studies. RESULTS: British commanders and psychiatrists argued that 'martial races' were protected against post-traumatic illnesses because of an innate resilience related to a rural heritage. Consequently, low morale and breakdown were interpreted as malingering to avoid combat. Indian troops received lower levels of psychiatric care than provided for British soldiers delivered with limited cultural understanding. Inferior terms and conditions were offered to Indian soldiers with lesser opportunities for promotion. These practices, established in both World Wars, continued for Gurkha and Commonwealth soldiers recruited to meet manpower and diversity targets. Disproportionate complaints of discrimination may explain why ethnic minority status is a risk factor for mental illness. CONCLUSION: Management patterns laid down during the Imperial era continue to influence current practice for ethnic minority service personnel. Yet, armed forces can play a positive role in fostering diversity and integration to provide protective factors against mental illness.

Piloting an approach to scab control on Welsh sheep farms.

Introduction: Sheep scab caused by Psoroptes ovis, is a disease of concern to many stakeholders in Wales due to its welfare implications. There are good diagnostic tests and treatments available to deal with the disease. Even so, it remains a problem in Welsh flocks. As such a coordinated approach is required to deal with this issue in a more sustainable manner. Pilot design: Sheep scab positive 'index' farms were initially diagnosed using a skin scrape to identify P. ovis mites. Contiguous farms were identified and antibody responses used to confirm onward infestation. All infested farms were treated by either dipping with an organophosphate (OP) dip or injecting with a licensed macrocyclic lactone (ML) product depending on farmer choice. Results: Three positive 'index' farms were identified along with 12 contiguous properties. Positive serological responses were observed in seven of the 12 contiguous farms; four of which were treated by OP dip and three by an injectable ML product. Discussion: To avoid reinfestation of treated farms, dealing with disease on contiguous properties is crucial. Through the project coordinating team, three local outbreaks of scab were dealt with in a short space of time with appropriate diagnosis and treatment being carried out. Some farmers were uncooperative and strategies such as providing additional external support and veterinary involvement might alleviate these issues in the future. This coordinated approach is recommended to veterinary surgeons in the field when dealing with scab on farm.

Combat exposure and co-occurring mental health problems in UK Armed Forces personnel.

BACKGROUND: Mental disorders and alcohol misuse are often comorbid, and this comorbidity is more common in those who develop mental disorders following exposure to traumatic events. AIMS: To investigate the relationship between combat exposure and operational role (support versus combat) with mental disorders and associated comorbidity in a UK military cohort. METHODS: 4896 participants from a UK military cohort reported their operational role and frequency of exposure to combat events during deployment. Outcome measures included self-reported post-traumatic stress disorder, common mental disorder and alcohol misuse. RESULTS: Personnel reporting higher levels of combat exposure were more likely to meet criteria for two or more co-occurring mental disorders (odds ratio [OR] 3.90, 95% confidence interval [CI] 2.73-5.58). While having a combat role increased the risk of developing co-occurring disorders compared to having a support role (OR 1.67, 95% CI 1.26-2.23), this effect diminished following adjustment for variables including combat exposure (OR 0.89, 95% CI 0.62-1.27). CONCLUSIONS: Combat exposure may play a greater role in the development of comorbid mental disorders than operational role, i.e. job title. Clinicians treating military personnel should be alert to the increased risk of comorbid mental disorders and alcohol misuse among those with a history of combat exposure.

COVID-19 and the Blitz compared: mental health outcomes in the UK.

The Blitz narrative of resilience stands in contrast to the mental health risks identified as consequences of the COVID-19 pandemic. Although evidence from then-classified studies of World War 2 showed that most people managed the stress of bombing, those vulnerable and exposed to substantial trauma had lasting or severe mental illness. Studies of different towns and occupational groups identified the proportion of people killed and wounded, the percentage of housing destroyed, and the loss of paid employment as risk factors for psychological breakdown. Mothers and children suffered not only with evacuation, but also from the trauma of bombing and damage to schools. A general association between civilian physical and psychological casualties suggests that population groups with high rates of infection and mortality might be susceptible to mental illness as a result of the pandemic. Lockdown and distancing measures contrast with the wartime sense of belonging and shared identity, reinforced by community networks and social activities.

The impact of moral injury on the wellbeing of UK military veterans.

BACKGROUND: Experiences of potentially morally injurious events (PMIEs) have been found to negatively impact the mental health of US personnel/veterans, yet little is known about the effect of PMIEs on the mental health of the UK Armed Forces (AF). This cross-sectional study aimed to examine the association between PMIEs and the mental health outcomes of UK AF veterans. METHOD: Assessments of PMIE exposure and self-report measures of common mental disorders were administered using an online questionnaire to 204 UK veterans. Subjects were classified as having experienced a morally injurious event (n = 66), a non-morally injurious traumatic event (n = 57), a 'mixed' event (n = 31), or no event (n = 50). RESULTS: Potentially morally injurious experiences were associated with adverse mental health outcomes, including likely anxiety disorders and suicidal ideation, compared to those who reported no event exposure. The likelihood of meeting criteria for probable PTSD was greatest in those who had experienced a non-morally injurious trauma. No statistically significant association between alcohol misuse and experiencing a PMIE or traumatic event was observed. CONCLUSIONS: The results provide preliminary evidence that potentially morally injurious experiences are associated with adverse mental health outcomes in UK AF veterans. Further work is needed to better understand the interplay between morally injurious events and threat-based trauma in order to design effective pathways for prevention and intervention for people exposed to highly challenging events.

What factors are truly associated with risk for radicalisation? A secondary data analysis within a UK sample.

Radicalisation and extremist violence are of increasing concern internationally. The unconventional, decentralised, and transnational nature of modern terrorism involves an active process of radicalisation requiring national security responses to reflect findings from recent empirical research. This study aims to identify factors that relate to extremist attitudes and potential vulnerability to radicalisation in order to inform preventative action. A cross-sectional survey was conducted of a representative population sample of men and women aged 18-45 of Muslim heritage recruited by quota sampling in two English cities. Logistic regressions were performed on a seven-item dichotomised measure based on our previously developed scale of 'sympathy for terrorist acts'. Scores representing 'non-condemnation of these acts' were deemed to represent risk for radicalisation. Thirteen respondents had a positive score on the sympathy for terrorism measure (2.4%), 39 scored zero (6.41%) and the remainder (91.4%) had a negative score representing condemnation of terrorist acts. There was a significant association between sympathy for terrorism and belonging to the local or global Muslim community, anxiety, and support for the use of defensive violence. Gender, religious identity, country of birth, belief in Sharia law, the importance of religion in life, and mosque attendance were all not associated with sympathy for terrorism. The results contribute to an understanding of the radicalisation process and have potential value in developing preventative public health interventions.

Delivering treatment to morally injured UK military personnel and Veterans: The clinician experience.

This study explored the experiences of clinicians in providing treatment in cases of military-related moral injury (MI). Qualitative interviews were carried out with 15 clinicians. Clinicians found patients experienced particular maladaptive appraisals following MI, which were considered different from the responses experienced after threat-based trauma. To address MI-related distress, clinicians utilized a range of treatment approaches. Several difficulties in providing care to patients following MI were described, including the impact of providing treatment on the clinicians own mental health. This study provides detailed insight into the approaches currently used to identify and treat UK Veterans with MI-related psychological problems. These findings highlight the need to evaluate the effectiveness of the treatments currently provided for MI-related psychological problems and suggest developing best practice guidance may improve clinician confidence in delivering care to those adversely impacted by MI.

The psychology of protecting the UK public against external threat: COVID-19 and the Blitz compared.

The COVID-19 pandemic and the World War 2 aerial bombing campaign against the UK between 1939 and 1945 both exposed the civilian population to a sustained threat. Risk, whether from exposure to viral load or the density of the bombing, led to a range of protective measures and behavioural regulations being implemented. The V1 and V2 missiles used in summer and autumn, 1944, functioned as a second wave of bombing, arriving after people believed the danger had passed. Adherence to lockdown and a reluctance to return to work after the lifting of lockdown during the COVID-19 pandemic in the UK were mirrored in the preference for using home-based bomb shelters during the air raids. Heightened sensitivity to risk, or a so-called deep shelter mentality, did not materialise even during the second wave of bomb attacks and some deep bomb shelters were closed because of low occupancy. The most popular protective measures were those that reflected people's preferences, and not necessarily those that provided the greatest safety. As with the COVID-19 pandemic, the public drove government policy as much as they followed it.

Assessing risks of violent extremism in depressive disorders: Developing and validating a new measure of Sympathies for Violent Protest and Terrorism.

OBJECTIVE: Clinicians are tasked with assessing the relationship between violence and mental illness. Yet, there is now a legal expectation in some countries that public services, including health professionals, assess risk of violent extremism - with few available measures. We previously developed a new measure of Sympathies for Radicalisation, using items that measure Sympathies for Violent Protest and Terrorism. In this paper, we present the detailed psychometric properties of a reduced item measure of Sympathies for Violent Protest and Terrorism. We use data from two studies to test replication and then validity against outcomes of self-reported violence and convictions in the entire sample and in those with depressive symptoms. METHODS: Data from two cross-sectional neighbourhood surveys, consisting of Pakistani and Bangladeshi adults (survey 1, n = 608) and White British and Pakistani adults (survey 2, n = 618), were used to undertake confirmatory factor analysis of Sympathies for Radicalisation and produce a short measure of Sympathies for Violent Protest and Terrorism. Survey 2 data were used to test the Sympathies for Violent Protest and Terrorism's convergent validity to classify presence/absence of violence and convictions in the whole sample and for subgroups by depressive disorder. RESULTS: The seven-item measure's structure was a consistent measure of extremist attitudes across the two surveys. A threshold score of zero to classify violence was optimal (specificity = 89.7%; area under the curve = 0.75), but sensitivity to a risk of violence was poor (34.5%). The short version Sympathies for Radicalisation was a better classifier of violence in respondents with depression, dysthymia or both (area under the curve = 0.78) than respondents with neither (area under the curve = 0.69; ß = 0.62, 95% confidence interval = [-0.67, 1.92]; standard error = 0.66). CONCLUSION: The seven-item measure of Sympathies for Violent Protest and Terrorism is an accessible and valid measure for clinical assessments and helpfully identifies low risk of violence. It enables clinicians to conduct detailed assessments of people endorsing one or more of the items, although further research is needed.

Moral injury in a context of trauma.

Moral injury, characterised by guilt, shame and self-condemnation, is conceptualised either as an adjunct to post-traumatic stress disorder or as a new syndrome. Studies of symptoms and potentially morally injurious events have produced a possible definition and informed the design of rating scales. The current challenge remains the design of effective interventions. Because moral injury relates to ethical behaviour, the meaning attached to events and perceptions of the self, moral philosophy and spirituality could contribute to the design of treatments.