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.

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.

Shared Mechanisms Govern HIV Transcriptional Suppression in Circulating CD103+ and Gut CD4+ T Cells.

Latent HIV infection is the main barrier to cure, and most HIV-infected cells reside in the gut, where distinct but unknown mechanisms may promote viral latency. Transforming growth factor ß (TGF-ß), which induces the expression of CD103 on tissue-resident memory T cells, has been implicated in HIV latency. Using CD103 as a surrogate marker to identify cells that have undergone TGF-ß signaling, we compared the HIV RNA/DNA contents and cellular transcriptomes of CD103+ and CD103- CD4 T cells from the blood and rectum of HIV-negative (HIV-) and antiretroviral therapy (ART)-suppressed HIV-positive (HIV+) individuals. Like gut CD4+ T cells, circulating CD103+ cells harbored more HIV DNA than did CD103- cells but transcribed less HIV RNA per provirus. Circulating CD103+ cells also shared a gene expression profile that is closer to that of gut CD4 T cells than to that of circulating CD103- cells, with significantly lower expression levels of ribosomal proteins and transcriptional and translational pathways associated with HIV expression but higher expression levels of a subset of genes implicated in suppressing HIV transcription. These findings suggest that blood CD103+ CD4 T cells can serve as a model to study the molecular mechanisms of HIV latency in the gut and reveal new cellular factors that may contribute to HIV latency.IMPORTANCE The ability of HIV to establish a reversibly silent, "latent" infection is widely regarded as the main barrier to curing HIV. Most HIV-infected cells reside in tissues such as the gut, but it is unclear what mechanisms maintain HIV latency in the blood or gut. We found that circulating CD103+ CD4+ T cells are enriched for HIV-infected cells in a latent-like state. Using RNA sequencing (RNA-seq), we found that CD103+ T cells share a cellular transcriptome that more closely resembles that of CD4+ T cells from the gut, suggesting that they are homing to or from the gut. We also identified the cellular genes whose expression distinguishes gut CD4+ or circulating CD103+ T cells from circulating CD103- T cells, including some genes that have been implicated in HIV expression. These genes may contribute to latent HIV infection in the gut and may serve as new targets for therapies aimed at curing HIV.

Circulating CD30+CD4+ T Cells Increase Before Human Immunodeficiency Virus Rebound After Analytical Antiretroviral Treatment Interruption.

BACKGROUND: Identification of nonviral markers of human immunodeficiency virus (HIV) infection that increase before viral rebound during analytical treatment interruption (ATI) may affect HIV persistence research. We previously showed that HIV ribonucleic acid (RNA) is enriched in CD30+CD4+ T cells in many individuals. Here, we studied CD30+CD4+ T-cell dynamics before ATI, during ATI (before detectable plasma RNA), and after HIV rebound. METHODS: Peripheral blood mononuclear cells from 23 participants collected longitudinally from 5 Adult AIDS Clinical Trials Group studies incorporating ATI were included in this study. Flow cytometric characterization of expression of CD30 and markers of T-cell activation and exhaustion were performed along with HIV-1 RNA and deoxyribonucleic acid quantification and measurement of soluble plasma CD30 and CD30 ligand. RESULTS: The percentage of CD4+ T cells expressing CD30 significantly increased from pre-ATI to postinterruption time points before detectible viremia (1.65 mean relative increase, P = .005). Seventy-seven percent of participants experienced an increase in CD30+ cells before viral rebound. In contrast, there were no significant differences between pre-ATI and postinterruption pre-rebound time points in percentages of lymphocytes expressing CD69, CD38/HLA-DR, or PD-1 until after HIV recrudescence. CONCLUSIONS: CD30 may be a surrogate marker of early replication or viral transcriptional activity before detection by routine peripheral blood sampling.

Long-Term Correlates of Mild Traumatic Brain Injury on Postconcussion Symptoms After Deployment to Iraq and Afghanistan in the UK Military.

OBJECTIVES: We assessed whether mild traumatic brain injury (mTBI) reported by UK service personnel between 2007 and 2009 was associated with postconcussion symptoms (PCS) 7 to 8 years later. SETTING: United Kingdom. PARTICIPANTS: A total of 4601 service personnel all of whom had deployed to Iraq and/or Afghanistan. DESIGN: Longitudinal study. MAIN OUTCOME MEASURES: Nine PCS reported in a survey carried out between 2014 and 2016. The main independent variable was mTBI reported between 2007 and 2009. RESULTS: A total of 2318 (50.4%) out of 4601 participants completed the follow-up questionnaire. Mild traumatic brain injury was associated with 2 of 9 PCS. Mild traumatic brain injury at baseline was associated with dizziness at follow-up in the fully adjusted model, in comparison with either "other injury" or "no injury" group. Mild traumatic brain injury was associated with loss of concentration in comparison with "no injury" but in comparison with the "other injury" group, it was not in the fully adjusted model. The prevalence of 7 of the 9 PCS increased over time regardless of mTBI status. CONCLUSIONS: Mild traumatic brain injury reported in 2007-2009 was associated with dizziness and possibly with loss of concentration 7 years later but not with most PCS. The prevalence of most PCS increased over time independently of mTBI.

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).

Mental health outcomes at the end of the British involvement in the Iraq and Afghanistan conflicts: a cohort study.

BACKGROUND: Little is known about the prevalence of mental health outcomes in UK personnel at the end of the British involvement in the Iraq and Afghanistan conflicts.AimsWe examined the prevalence of mental disorders and alcohol misuse, whether this differed between serving and ex-serving regular personnel and by deployment status. METHOD: This is the third phase of a military cohort study (2014-2016; n = 8093). The sample was based on participants from previous phases (2004-2006 and 2007-2009) and a new randomly selected sample of those who had joined the UK armed forces since 2009. RESULTS: The prevalence was 6.2% for probable post-traumatic stress disorder, 21.9% for common mental disorders and 10.0% for alcohol misuse. Deployment to Iraq or Afghanistan and a combat role during deployment were associated with significantly worse mental health outcomes and alcohol misuse in ex-serving regular personnel but not in currently serving regular personnel. CONCLUSIONS: The findings highlight an increasing prevalence of post-traumatic stress disorder and a lowering prevalence of alcohol misuse compared with our previous findings and stresses the importance of continued surveillance during service and beyond. DECLARATION OF INTEREST: All authors are based at King's College London which, for the purpose of this study and other military-related studies, receives funding from the UK Ministry of Defence (MoD). S.A.M.S., M.J., L.H., D.P., S.M. and R.J.R. salaries were totally or partially paid by the UK MoD. The UK MoD provides support to the Academic Department of Military Mental Health, and the salaries of N.J., N.G. and N.T.F. are covered totally or partly by this contribution. D.Mu. is employed by Combat Stress, a national UK charity that provides clinical mental health services to veterans. D.MacM. is the lead consultant for an NHS Veteran Mental Health Service. N.G. is the Royal College of Psychiatrists' Lead for Military and Veterans' Health, a trustee of Walking with the Wounded, and an independent director at the Forces in Mind Trust; however, he was not directed by these organisations in any way in relation to his contribution to this paper. N.J. is a full-time member of the armed forces seconded to King's College London. N.T.F. reports grants from the US Department of Defense and the UK MoD, is a trustee (unpaid) of The Warrior Programme and an independent advisor to the Independent Group Advising on the Release of Data (IGARD). S.W. is a trustee (unpaid) of Combat Stress and Honorary Civilian Consultant Advisor in Psychiatry for the British Army (unpaid). S.W. is affiliated to the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emergency Preparedness and Response at King's College London in partnership with Public Health England, in collaboration with the University of East Anglia and Newcastle University. The views expressed are those of the author(s) and not necessarily those of the National Health Service, the NIHR, the Department of Health, Public Health England or the UK MoD.

Combat Experiences and their Relationship to Post-Traumatic Stress Disorder Symptom Clusters in UK Military Personnel Deployed to Afghanistan.

The association of post-traumatic stress disorder (PTSD) symptom clusters with combat and other operational experiences among United Kingdom Armed Forces (UK AF) personnel who deployed to Afghanistan in 2009 were examined. Previous studies suggest that the risk of developing PTSD rises as combat exposure levels increase. To date, no UK research has investigated how specific classes of combat and operational experiences relate to PTSD symptom clusters. The current study was a secondary analysis of data derived from a two-arm cluster, randomized-controlled trial of a postdeployment operational stress-reduction intervention in deployed UK AF personnel. 2510 UK AF personnel provided combat exposure data and completed the PTSD checklist (civilian version) immediately post-deployment while 1635 of the original cohort completed further followed-up measures four to six months later. A 14-item combat experience scale was explored using principle component analysis, which yielded three main categories of experience: (1) violent combat, (2) proximity to wounding or death and (3) encountering explosive devices. The association of combat experience classes to PTSD 5-factor "dysphoric arousal" model (re-experiencing, avoidance, numbing, dysphoric-arousal and anxious-arousal symptoms) was assessed. Greater exposure to violent combat was predictive of re-experiencing and numbing symptoms, while proximity to wounding or death experiences were predictive of re-experiencing and anxious-arousal symptoms. Explosive device exposure was predictive of anxious-arousal symptoms. The present study suggests that categories of combat experience differentially impact on PTSD symptom clusters and may have relevance for clinicians treating military personnel following deployment.

Cohesion, leadership, mental health stigmatisation and perceived barriers to care in UK military personnel.

BACKGROUND: Military research suggests a significant association between leadership, cohesion, mental health stigmatisation and perceived barriers to care (stigma/BTC). AIM: Most studies are cross sectional, therefore longitudinal data were used to examine the association of leadership and cohesion with stigma/BTC. METHOD: Military personnel provided measures of leadership, cohesion, stigma/BTC, mental health awareness and willingness to discuss mental health following deployment (n = 2510) and 4-6 months later (n = 1636). RESULTS: At follow-up, baseline leadership and cohesion were significantly associated with stigma/BTC; baseline cohesion alone was significantly associated with awareness of and willingness to discuss mental health at follow-up. Over time, changes in perceived leadership and cohesion were significantly associated with corresponding changes in stigma/BTC levels. Stigma/BTC content was similar in both surveys; fear of being viewed as weak and being treated differently by leaders was most frequently endorsed while thinking less of a help-seeking team member and unawareness of potential help sources were least common. CONCLUSION: Effective leadership and cohesion building may help to reduce stigma/BTC in military personnel. Mental health awareness and promoting the discussion of mental health matters may represent core elements of supportive leader behaviour. Perceptions of weakness and fears of being treated differently represent a focus for stigma/BTC reduction.

The long term occupational fitness of UK military personnel following community mental health care.

BACKGROUND: Fitness to undertake operational deployment is a key requirement of military service. AIM: To assess individual deployment fitness at a single point from one month to eight years following discharge from mental healthcare. METHOD: Survival analyses assessed levels of deployability; the predictive effects of key covariates upon time to being classified as non-deployable were examined using univariate and multivariate Cox proportional hazards regression procedures. RESULTS: A total of 1405 individuals provided study data. 437 individuals (31.1%) were non-deployable or discharged from service during follow-up. 17.2% were non-deployable in the first year following mental healthcare; the proportion did not rise above this level until year seven when it was 19.1% and then 30.6% in year eight. Risk factors for being classified as non-deployable were female sex, receipt of intermediate duration therapy, management by the multidisciplinary team and previous referral to mental health services. Previous deployment was significantly associated with reduced risk. Overall, the levels of non-deployability appeared to be no higher than those found among the wider military services. CONCLUSION: Non-deployable status among mental healthcare recipients was broadly similar to that found among the wider UK military; risk factors for non-deployability could be amenable to targeted relapse prevention measures.

What drives UK military personnel to seek mental healthcare, work strain or something else?

BACKGROUND: The numbers of UK military personnel referred to military departments of community mental health (DCMH) have increased annually over recent years; the reasons for such an increase are unclear. METHOD: Data for this study were derived from 549 DCMH attendees and 3682 serving regular military personnel. DCMH attendees completed a checklist of potential reasons for help-seeking. Cohort members provided data on perceived mental health problems and help-seeking from specialist mental health services. Both samples provided work strain and basic sociodemographic data. Work strain levels were compared among cohort and DCMH help seekers and non-help seekers using adjusted logistic regression analyses. RESULTS: Perceiving that mental health-related stigmatisation had reduced and being prompted to seek help by attending a health promotion event were among the least frequent reasons for seeking help in DCMH attendees. Realising that help was needed and being urged to seek help by one's partner, friends or family were the most common. Working very hard and experiencing excessive work were the most common work strain factors. Overall, the greatest levels of work strain were found among DCMH attendees. In all subsamples, work strain was significantly associated with experiencing a perceived mental health problem irrespective of whether help was sought or not. CONCLUSION: Work strain was significantly associated with experiencing a stressful, emotional, mental health or alcohol problem and was the highest among current DCMH help seekers. Recognising that help was required and being prompted by a significant other were the main drivers for help-seeking among DCMH attendees.

UK military doctors; stigma, mental health and help-seeking: a comparative cohort study.

INTRODUCTION: Studies suggest that medical doctors can suffer from substantial levels of mental ill-health. Little is known about military doctors' mental health and well-being; we therefore assessed attitudes to mental health, self-stigma, psychological distress and help-seeking among UK Armed Forces doctors. METHODS: Six hundred and seventy-eight military doctors (response rate 59%) completed an anonymous online survey. Comparisons were made with serving and ex-military personnel (n=1448, response rate 84.5%) participating in a mental health-related help-seeking survey. Basic sociodemographic data were gathered, and participants completed measures of mental health-related stigmatisation, perceived barriers to care and the 12-Item General Health Questionnaire. All participants were asked if in the last three years they had experienced stress, emotional, mental health, alcohol, family or relationship problems, and whether they had sought help from formal sources. RESULTS: Military doctors reported fewer mental disorder symptoms than the comparison groups. They endorsed higher levels of stigmatising beliefs, negative attitudes to mental healthcare, desire to self-manage and self-stigmatisation than each of the comparison groups. They were most concerned about potential negative effects of and peer perceptions about receiving a mental disorder diagnosis. Military doctors reporting historical and current relationship, and alcohol or mental health problems were significantly and substantially less likely to seek help than the comparison groups. CONCLUSIONS: Although there are a number of study limitations, outcomes suggest that UK military doctors report lower levels of mental disorder symptoms, higher levels of stigmatising beliefs and a lower propensity to seek formal support than other military reference groups.

The health of UK civilians deployed to Iraq.

Background: Modern military operations have incorporated deployed civilians in a variety of roles (e.g. diplomats, private security staff). Many of these roles expose individuals to potentially dangerous or traumatic events. Evidence has shown that such exposures can cause psychological health problems in military personnel. It is likely that the same would be seen among civilians working in such environments. There is however limited research into the health of civilians deployed to war zones. This study compared health outcomes and related behaviours among UK regular and reserve Army personnel with UK civilian personnel deployed in direct support of the UK military in Iraq. Methods: The study sample comprised of 159 Ministry of Defence civilians, 1542 Army regulars and 408 Army reservists, all of whom served in non-combat roles. Data were gathered by questionnaires which asked about deployment experiences, lifestyle factors and health outcomes [i.e. post-traumatic stress disorder (PTSD), general health, multiple physical symptoms and alcohol use]. Results: Fewer deployed UK civilians smoked than regular Army personnel (adjusted OR 0.83 95% CI 0.70-0.98). UK civilians had better overall health and were less likely to report multiple physical symptoms compared with reservists (adjusted ORs 0.64 95% CI 0.44-0.93 and 0.60 95% CI 0.39-0.93, respectively). Conclusions: Overall, the psychological health of deployed civilians appears to be better than that of Army personnel deployed in non-combat roles. Civilians are also less likely to engage in some risky behaviours.

The mental health of deployed UK maritime forces.

OBJECTIVES: To establish the level of psychological symptoms and the risk factors for possible decreased mental health among deployed UK maritime forces. METHODS: A survey was completed by deployed Royal Navy (RN) personnel which measured the prevalence of common mental disorder (CMD), post-traumatic stress disorder (PTSD) and potential alcohol misuse. Military and operational characteristics were also measured including exposure to potentially traumatic events, problems occurring at home during the deployment, unit cohesion, leadership and morale. Associations between variables of interest were identified using binary logistic regression to generate ORs and 95% CIs adjusted for a range of potential confounding variables. RESULTS: In total, 41.2% (n=572/1387) of respondents reported probable CMD, 7.8% (n=109/1389) probable PTSD and 17.4% (n=242/1387) potentially harmful alcohol use. Lower morale, cohesion, leadership and problems at home were associated with CMD; lower morale, leadership, problems at home and exposure to potentially traumatic events were associated with probable PTSD; working in ships with a smaller crew size was associated with potentially harmful alcohol use. CONCLUSIONS: CMD and PTSD were more frequently reported in the maritime environment than during recent land-based deployments. Rates of potentially harmful alcohol use have reduced but remain higher than the wider military. Experiencing problems at home and exposure to potentially traumatic events were associated with experiencing poorer mental health; higher morale, cohesion and better leadership with fewer psychological symptoms.

Prevalence of PTSD and other mental disorders in UK service personnel by time since end of deployment: a meta-analysis.

BACKGROUND: US studies have shown an increase of posttraumatic stress disorder (PTSD) and depression, but not alcohol misuse related to time of assessment since returning from deployment. We assessed if similar trends occur in the UK Armed Forces. METHODS: We selected UK studies based on our data base of King's Centre for Military Health Research publications from 2006 until January 2016 with at least one of the following measures: PTSD checklist-civilian version (PCL-C), the General Health Questionnaire (GHQ-12) and the Alcohol Use Disorders Identification Test (AUDIT). The studies included personnel assessed for these outcomes after their most recent deployment. A search in Medline, Psycho-Info and Embase confirmed that no relevant publication was missed. RESULTS: Twenty one thousand, seven hundred and forty-six deployed personnel from nine studies contributed to the meta-analyses by time since end of deployment in the PTSD analysis. The number of studies for period of time varied from two to four studies. The trend by time-category of questionnaire completion since returning from deployment were for PTSD ß = 0.0021 (95 % CI -0.00046 to 0.0049, p = 0.12), for psychological distress ß = 0.0123 (95 % CI 0.005 to 0.019, p = 0.002) and for alcohol misuse ß = 0.0013 (-0.0079 to 0.0105, p = 0.77). CONCLUSIONS: There was no evidence that the prevalence of PTSD and alcohol misuse changed according to time since the end of deployment over a three-year period, but there was evidence for an association with increasing psychological distress.

A High-Resolution National-Scale Hydrologic Forecast System from a Global Ensemble Land Surface Model.

Warning systems with the ability to predict floods several days in advance have the potential to benefit tens of millions of people. Accordingly, large-scale streamflow prediction systems such as the Advanced Hydrologic Prediction Service or the Global Flood Awareness System are limited to coarse resolutions. This article presents a method for routing global runoff ensemble forecasts and global historical runoff generated by the European Centre for Medium-Range Weather Forecasts model using the Routing Application for Parallel computatIon of Discharge to produce high spatial resolution 15-day stream forecasts, approximate recurrence intervals, and warning points at locations where streamflow is predicted to exceed the recurrence interval thresholds. The processing method involves distributing the computations using computer clusters to facilitate processing of large watersheds with high-density stream networks. In addition, the Streamflow Prediction Tool web application was developed for visualizing analyzed results at both the regional level and at the reach level of high-density stream networks. The application formed part of the base hydrologic forecasting service available to the National Flood Interoperability Experiment and can potentially transform the nation's forecast ability by incorporating ensemble predictions at the nearly 2.7 million reaches of the National Hydrography Plus Version 2 Dataset into the national forecasting system.

Stigma as a barrier to seeking health care among military personnel with mental health problems.

Approximately 60% of military personnel who experience mental health problems do not seek help, yet many of them could benefit from professional treatment. Across military studies, one of the most frequently reported barriers to help-seeking for mental health problems is concerns about stigma. It is, however, less clear how stigma influences mental health service utilization. This review will synthesize existing research on stigma, focusing on those in the military with mental health problems. We conducted a systematic review and meta-analysis of studies between 2001 and 2014 to examine the prevalence of stigma for seeking help for a mental health problem and its association with help-seeking intentions/mental health service utilization. Twenty papers met the search criteria. Weighted prevalence estimates for the 2 most endorsed stigma concerns were 44.2% (95% confidence interval: 37.1, 51.4) for "My unit leadership might treat me differently" and 42.9% (95% confidence interval: 36.8, 49.0) for "I would be seen as weak." Nine studies found no association between anticipated stigma and help-seeking intentions/mental health service use and 4 studies found a positive association. One study found a negative association between self-stigma and intentions to seek help. Counterintuitively, those that endorsed high anticipated stigma still utilized mental health services or were interested in seeking help. We propose that these findings may be related to intention-behavior gaps or methodological issues in the measurement of stigma. Positive associations may be influenced by modified labeling theory. Additionally, other factors such as self-stigma and negative attitudes toward mental health care may be worth further attention in future investigation.

Medical and Welfare Officers beliefs about post-deployment screening for mental health disorders in the UK Armed Forces: a qualitative study.

BACKGROUND: This study aimed to examine currently serving United Kingdom (UK) military Medical and Welfare Officers views on the potential introduction of post-deployment screening for mental ill health. METHODS: Semi-structured interviews were conducted with 21 Medical and Welfare Officers. Interview transcripts were analysed using data-driven thematic analysis. RESULTS: Four themes were identified: positive views of screening; reliability of responses; impact on workload; and suggestions for implementation. Interviewees viewed the introduction of screening post-deployment as likely to increase awareness of mental health problems whilst also reporting that service personnel were likely to conceal their true mental health status by providing misleading responses to any screening tool. Concern over reliability of responses may provide one explanation for the reluctance of service personnel to seek help for problems, as they could feel they will not be taken seriously. Welfare Officers felt they would not have the knowledge or experience to respond to help-seeking. Although participants were concerned about potential impact on their personal workload, they indicated a desire to positively engage with the screening programme if research showed it was an effective tool to improve mental health care. CONCLUSIONS: Welfare and healthcare providers are well disposed towards a screening programme for mental health but highlight a few concerns in its implementation. In particular Welfare Officers appear to require more training in how to respond to mental ill health. Concerns about available funding and resources to respond to increased workload will need to be addressed should post-deployment screening for mental health be introduced in the UK military.

Stigmatisation, perceived barriers to care, help seeking and the mental health of British Military personnel.

INTRODUCTION: The relationship between mental health symptoms, stigmatising beliefs about mental health and help seeking is complex and poorly understood. METHOD: 1636 UK Armed Forces personnel provided study data immediately after deployment (T1) and approximately 6 months later (T2). Stigmatising beliefs were assessed using an eight-item scale previously used in studies of UK military personnel. Symptoms of probable common mental disorder, probable post-traumatic stress disorder and subjective stressful, emotional, relationship and family problems were evaluated at T1 and T2. Help seeking during deployment was assessed at T1 and post-deployment help seeking at T2. Alcohol use and subjective alcohol problems were assessed at T2 only. RESULTS: Reporting a probable mental health disorder or potentially harmful alcohol use following deployment was both significantly associated with higher levels of stigmatising beliefs. The reported degree of stigma was associated with changes in mental health symptom levels; compared to those who were never classified as a probable mental health disorder case, recovered cases experienced significantly lower levels of stigmatisation, whereas new onset cases reported significantly higher levels. CONCLUSION: The way that individuals report mental health stigmatisation is not static; rather stigma fluctuates in proportion to the frequency and severity of psychological symptoms. These results suggest that public health stigma-reduction strategies which aim to promote engagement with mental health services should be focused towards people who are experiencing worsening mental health. Our results suggest that willing volunteers who have recovered from a mental-ill-health episode may be well placed to assist in the delivery of such a strategy.