Military veterans and civilians' mental health diagnoses: an analysis of secondary mental health services.

PURPOSE: Healthcare provision in the United Kingdom (UK) falls primarily to the National Health Service (NHS) which is free at the point of access. In the UK, there is currently no national marker to identify military veterans in electronic health records, nor a requirement to record it. This study aimed to compare the sociodemographic characteristics and recorded mental health diagnoses of a sample of veterans and civilians accessing secondary mental health services. METHODS: The Military Service Identification Tool, a machine learning computer tool, was employed to identify veterans and civilians from electronic health records. This study compared the sociodemographic characteristics and recorded mental health diagnoses of veterans and civilians accessing secondary mental health care from South London and Maudsley NHS Foundation Trust, UK. Data from 2,576 patients were analysed; 1288 civilians and 1288 veterans matched on age and gender. RESULTS: Depressive disorder was the most prevalent across both groups in the sample (26.2% veterans, 15.5% civilians). The present sample of veterans accessing support for mental health conditions were significantly more likely to have diagnoses of anxiety, depressive, psychosis, personality, and stress disorders (AORs ranging 1.41-2.84) but less likely to have a drug disorder (AOR = 0.51) than age- and gender-matched civilians. CONCLUSION: Veterans accessing secondary mental health services in South London had higher risks for many mental health problems than civilians accessing the same services. Findings suggest that military career history is a key consideration for probable prognosis and treatment, but this needs corroborating in other geographical areas including national population-based studies in the UK.

A comparison of probable post-traumatic stress disorder and alcohol consumption among active female members of the UK Police Service and UK Armed Forces.

BACKGROUND: The British Police Service and Armed Forces are male-dominated occupations, characterised by frequent trauma exposure and intensive demands. Female police employees and military personnel may have unique experiences and face additional strains to their male counterparts. This analysis compared the levels of post-traumatic stress disorder (PTSD), hazardous/harmful alcohol consumption, and comorbidity in female police employees and military personnel. METHODS: Police data were obtained from the Airwave Health Monitoring Study (N = 14,145; 2007-2015) and military data from the Health and Wellbeing Cohort Study (N = 928; phase 2: 2007-2009 and phase 3: 2014-2016). Multinomial/logistic regressions analysed sample differences in probable PTSD, hazardous (14-35 units per week) and harmful (35 + units per week) alcohol consumption, and comorbid problems. We compared covariate adjustment and entropy balancing (reweighting method controlling for the same covariates) approaches. RESULTS: There were no significant differences in probable PTSD (police: 3.74% vs military: 4.47%) or hazardous drinking (police: 19.20% vs military: 16.32%). Female military personnel showed significantly higher levels of harmful drinking (4.71%) than police employees (2.42%; Adjusted Odds Ratios [AOR] = 2.26, 95% Confidence Intervals [CIs] = 1.60-3.21), and comorbidity (1.87%) than police employees (1.00%, AOR = 2.07, 95% CI = 1.21-3.54). Entropy balancing and covariate-adjustments obtained the same results. CONCLUSIONS: Comparable levels of probable PTSD were observed, which are slightly lower than estimates observed in the female general population. Future research should explore the reasons for this. However, female military personnel showed higher levels of harmful drinking than police employees, emphasising the need for alcohol interventions in military settings.

Association between combat-related traumatic injury and cardiovascular risk.

OBJECTIVE: The association between combat-related traumatic injury (CRTI) and cardiovascular risk is uncertain. This study aimed to investigate the association between CRTI and both metabolic syndrome (MetS) and arterial stiffness. METHODS: This was a prospective observational cohort study consisting of 579 male adult UK combat veterans (UK-Afghanistan War 2003-2014) with CRTI who were frequency-matched to 565 uninjured men by age, service, rank, regiment, deployment period and role-in-theatre. Measures included quantification of injury severity (New Injury Severity Score (NISS)), visceral fat area (dual-energy X-ray absorptiometry), arterial stiffness (heart rate-adjusted central augmentation index (cAIx) and pulse wave velocity (PWV)), fasting venous blood glucose, lipids and high-sensitivity C reactive protein (hs-CRP). RESULTS: Overall the participants were 34.1±5.4 years, with a mean (±SD) time from injury/deployment of 8.3±2.1 years. The prevalence of MetS (18.0% vs 11.8%; adjusted risk ratio 1.46, 95% CI 1.10 to 1.94, p<0.0001) and the mean cAIx (17.61%±8.79% vs 15.23%±8.19%, p<0.0001) were higher among the CRTI versus the uninjured group, respectively. Abdominal waist circumference, visceral fat area, triglycerides, estimated insulin resistance and hs-CRP levels were greater and physical activity and high-density lipoprotein-cholesterol lower with CRTI. There were no significant between-group differences in blood glucose, blood pressure or PWV. CRTI, injury severity (↑NISS), age, socioeconomic status (SEC) and physical activity were independently associated with both MetS and cAIx. CONCLUSIONS: CRTI is associated with an increased prevalence of MetS and arterial stiffness, which are also influenced by age, injury severity, physical activity and SEC. The longitudinal impact of CRTI on clinical cardiovascular events needs further examination.

UK veterans' mental health and well-being before and during the COVID-19 pandemic: a longitudinal cohort study.

OBJECTIVE: To investigate the impact of the COVID-19 pandemic on the health and well-being of UK ex-service personnel (veterans) before and during the pandemic, and to assess associations of COVID-19 experiences and stressors with mental health, alcohol use and loneliness. DESIGN: An additional wave of data was collected from a longitudinal cohort study of the UK Armed Forces. SETTING: Online survey June-September 2020. PARTICIPANTS: Cohort members were included if they had completed a questionnaire at phase 3 of the King's Centre for Military Health Research health and well-being study (2014-2016), had left the Armed Forces after regular service, were living in the UK, had consented to follow-up and provided a valid email address. Invitation emails were sent to N=3547 with a 44% response rate (n=1562). PRIMARY OUTCOME MEASURES: Common mental health disorders (CMDs) (measured using the General Health Questionnaire, 12 items-cut-off ≥4), hazardous alcohol use (measured using the Alcohol Use Disorder Identification Test, 10 items-cut off ≥8) and loneliness (University of California, Los Angeles, Loneliness Scale- 3 items-cut-off ≥6). RESULTS: Veterans reported a statistically significant decrease in hazardous drinking of 48.5% to 27.6%, while CMD remained stable (non-statistically significant increase of 24.5% to 26.1%). 27.4% of veterans reported feelings of loneliness. The COVID-19 stressors of reporting difficulties with family/social relationships, boredom and difficulties with health were statistically significantly associated with CMD, hazardous drinking and loneliness, even after adjustment for previous mental health/hazardous alcohol use. CONCLUSIONS: Our study suggests a COVID-19 impact on veterans' mental health, alcohol use and loneliness, particularly for those experiencing difficulties with family relationships. Veterans experienced the pandemic in similar ways to the general population and in some cases may have responded in resilient ways. While stable levels of CMD and reduction in alcohol use are positive, there remains a group of veterans who may need mental health and alcohol treatment services.

Probable post-traumatic stress disorder and harmful alcohol use among male members of the British Police Forces and the British Armed Forces: a comparative study.

Background: British Armed Forces' and Police Forces' personnel are trained to operate in potentially traumatic conditions. Consequently, they may experience post-traumatic stress disorder (PTSD), which is often comorbid with harmful alcohol use. Objective: We aimed to assess the proportions, and associations, of probable PTSD and harmful alcohol use among a covariate-balanced sample of male military personnel and police employees. Methods: Proportions of probable PTSD, harmful alcohol use, and daily binge drinking, were explored using data from the police Airwave Health Monitoring Study (2007-2015) (N = 23,826) and the military Health and Wellbeing Cohort Study (phase 2: 2007-2009, phase 3: 2014-2016) (N = 7,399). Entropy balancing weights were applied to the larger police sample to make them comparable to the military sample on a range of pre-specified variables (i.e. year of data collection, age and education attainment). Multinomial and logistic regression analyses determined sample differences in outcome variables, and associated factors (stratified by sample). Results: Proportions of probable PTSD were similar in military personnel and police employees (3.67% vs 3.95%), although the large sample size made these borderline significant (Adjusted Odds Ratio (AOR): 0.84; 95% Confidence Intervals (CI): 0.72 to 0.99). Clear differences were found in harmful alcohol use among military personnel, compared to police employees (9.59% vs 2.87%; AOR: 2.79; 95% CI: 2.42 to 3.21). Current smoking, which was more prevalent in military personnel, was associated with harmful drinking and binge drinking in both samples but was associated with PTSD in military personnel only. Conclusions: It is generally assumed that both groups have high rates of PTSD from traumatic exposures, however, low proportions of PTSD were observed in both samples, possibly reflecting protective effects of unit cohesion or resilience. The higher level of harmful drinking in military personnel may relate to more prominent drinking cultures or unique operational experiences.

Antecedentes: El personal de las fuerzas armadas británicas y de la policía británica está entrenado para operar en condiciones potencialmente traumáticas. Consecuentemente, pueden experimentar trastorno de estrés postraumático (TEPT), el cual es frecuentemente comórbido con uso nocivo de alcohol.Objetivo: Buscamos evaluar las proporciones, y asociaciones, del probable TEPT y del uso nocivo de alcohol en una muestra balanceada por covariables de personal masculino, militares y empleados de policía.Métodos: Las proporciones de probable TEPT, uso nocivo de alcohol y atracones diarios de alcohol, fueron exploradas utilizando datos del estudio Airwave Health Monitoring Study de la policía (2007-2015) (N=23,826) y del estudio militar Health and Wellbeing Cohort Study (fase 2: 2007-2009, fase 3: 2014-2016) (N=7,399). Se aplicaron pesos de balance de entropía a la muestra más grande, de policía, para hacerla comparable a la muestra militar en un rango de variables pre-especificadas (ej. año de recolección de datos, edad y logros educacionales). Los análisis multinomiales y de regresión logística determinaron diferencias muestrales en las variables de resultado, y en los factores asociados (estratificados por muestra).Resultados: Las proporciones de TEPT probable fueron similares en el personal militar y los empleados de policía (3,67% vs 3,95%), aunque el gran tamaño muestral hizo fuera significativo al límite (Razón de probabilidades ajustada (AOR): 0.84; Intervalo de Confianza (IC) de 95%: 0.72 a 0.99). Se encontraron claras diferencias en el uso nocivo de alcohol entre el personal militar, comparado a los empleados de policía (9,59% vs 2.87%; AOR: 2.79; IC 95%: 2.42 a 3.21). El consumo actual de tabaco, que fue más prevalente en el personal militar, se asoció a consumo nocivo de alcohol y a atracones de alcohol en ambas muestras, pero se asoció a TEPT sólo en el personal militar.Conclusiones: Generalmente se asume que ambos grupos tienen altas tasas de TEPT desde la exposición traumática, sin embargo, se observó una baja proporción de TEPT en ambas muestras, lo que probablemente refleja el efecto protector de la cohesión de unidad o la resiliencia. El mayor nivel de consumo nocivo de alcohol en el personal militar puede estar relacionado una cultura de consumo de alcohol más prominente o a experiencias operacionales únicas.

Probable PTSD, depression and anxiety in 40,299 UK police officers and staff: Prevalence, risk factors and associations with blood pressure.

INTRODUCTION: Police employees undertake challenging duties which may adversely impact their health. This study explored the prevalence of and risk factors for probable mental disorders amongst a representative sample of UK police employees. The association between mental illness and alterations in blood pressure was also explored. METHODS: Data were used from the Airwave Health Monitoring Study which was established to monitor the possible physical health impacts of a new communication system on police employees. Data included sociodemographic characteristics, lifestyle habits, depression, anxiety, and post-traumatic stress disorder (PTSD) symptoms and blood pressure. Descriptive statistics were used to explore the prevalence of probable mental disorders and associated factors. Stepwise linear regression was conducted, controlling for confounding variables, to examine associations between mental disorders and blood pressure. RESULTS: The sample included 40,299 police staff, police constable/sergeants and inspectors or above. Probable depression was most frequently reported (9.8%), followed by anxiety (8.5%) and PTSD (3.9%). Groups at risk for probable mental disorders included police staff, and police employees who reported drinking heavily. Police employees exposed to traumatic incidents in the past six months had a doubling in rates of anxiety or depression and a six-fold increase in PTSD compared to those with no recent trauma exposure. Adjusted logistic regression models did not reveal any significant association between probable mental disorders and systolic blood pressure but significantly elevated diastolic blood pressure (≈1mmHg) was found across mental disorders. CONCLUSIONS: These results show lower rates of probable mental disorders, especially PTSD, than reported in other studies focusing on police employees. Although mental ill health was associated with increased diastolic blood pressure, this was unlikely to be clinically significant. These findings highlight the importance of continued health monitoring of members of the UK police forces, focusing on employees recently exposed to traumatic incidents, heavy drinkers and police staff.

The mental health of emergency services personnel in the UK Biobank: a comparison with the working population.

Background: There is evidence that mental disorders are more frequently reported among emergency services personnel due to the stressful nature of the job in combination with a high exposure to traumatic events. However, most of this research is based on occupational surveys that may lead to a contextual bias in the prevalence estimates or lack an adequate comparison group. Objectives: To investigate mental health outcomes and associations with individual, job and trauma related characteristics among emergency services personnel compared to other workers. Method: Participants were identified from the UK Biobank, a large study that collected a variety of genetic, physical and health data on individuals from across the UK. UK Biobank participants were aged between 40-69 years at recruitment. Those employed in the emergency services were identified based on job titles. A comparison sample of other workers was selected and matched to the gender composition of emergency services personnel. Results: 5052 participants were included, and 842 were currently working in the emergency services. The majority were male (77.4%) and the mean age at Biobank enrolment was 52.5 years. Alcohol misuse was reported in 32.8% of emergency services personnel compared to 29.2% in non-emergency services personnel, followed by PTSD (9.2% vs 6.0%), depression (6.8% vs 5.1%) and anxiety (3.9% vs 3.6%). An increased risk of PTSD was found among emergency services personnel compared to other workers (odds ratio 1.58, 95% confidence interval 1.21-2.06), but this association was no longer significant after adjustment for exposure to traumatic events and job characteristics. Conclusions: The substantial levels of alcohol misuse and increased risk of PTSD, possibly as a result of traumatic exposures in the line of duty in combination with job stressors such as shift work, call for continued monitoring of the health and wellbeing of emergency services personnel.

Antecedentes: Existe evidencia de que los trastornos mentales son reportados con mayor frecuencia entre el personal de servicios de emergencia debido a la naturaleza estresante del trabajo, en combinación, con una alta exposición a eventos traumáticos. Sin embargo, la mayor parte de esta línea de investigación se basa en encuestas ocupacionales que pueden conducir a un sesgo contextual en las estimaciones de prevalencia o carecer de un adecuado grupo de comparación.Objetivos: Investigar los resultados de salud mental y las asociaciones con características individuales, laborales y relacionadas con trauma entre el personal de servicios de emergencia en comparación con otros trabajadores.Método: Los participantes del Biobanco del Reino Unido tenían entre 40 y 69 años al momento del reclutamiento. Los empleados en los servicios de emergencia se identificaron utilizando los códigos de Clasificación Ocupacional Estándar 2000, y la frecuencia se ajustó a una muestra aleatoria de participantes, equivalentes según género, que trabajaban en otras ocupaciones.Resultados: Se incluyeron 5052 participantes y 842 estaban en ese momento trabajando en los servicios de emergencia. La mayoría eran hombres (77,4%) y la edad media de inscripción en el Biobanco fue de 52,5 años. El abuso de alcohol se reportó en el 32.8% del personal de servicios de emergencia en comparación con el 29.2% en el personal de servicios que no eran de emergencia, seguido de TEPT (9.2% vs 6.0%), depresión (6.8% vs 5.1%) y ansiedad (3.9% vs 3.6%). Se encontró un mayor riesgo de TEPT entre el personal de servicios de emergencia en comparación con otros trabajadores (odds ratio 1.58, intervalo de confianza del 95% 1.21-2.06), pero esta asociación dejó de ser significativa después del ajuste por exposición a eventos traumáticos y características del trabajo. Los factores más fuertemente asociados con los resultados adversos de salud mental en ambos grupos de trabajadores incluyeron la exposición a eventos traumáticos.Conclusiones: Los niveles sustanciales de abuso de alcohol y el mayor riesgo de TEPT, posiblemente como resultado de exposiciones traumáticas en cumplimiento de sus funciones, requieren un monitoreo continuo de la salud y el bienestar del personal de servicios de emergencia.

The Development of the Military Service Identification Tool: Identifying Military Veterans in a Clinical Research Database Using Natural Language Processing and Machine Learning.

BACKGROUND: Electronic health care records (EHRs) are a rich source of health-related information, with potential for secondary research use. In the United Kingdom, there is no national marker for identifying those who have previously served in the Armed Forces, making analysis of the health and well-being of veterans using EHRs difficult. OBJECTIVE: This study aimed to develop a tool to identify veterans from free-text clinical documents recorded in a psychiatric EHR database. METHODS: Veterans were manually identified using the South London and Maudsley (SLaM) Biomedical Research Centre Clinical Record Interactive Search-a database holding secondary mental health care electronic records for the SLaM National Health Service Foundation Trust. An iterative approach was taken; first, a structured query language (SQL) method was developed, which was then refined using natural language processing and machine learning to create the Military Service Identification Tool (MSIT) to identify if a patient was a civilian or veteran. Performance, defined as correct classification of veterans compared with incorrect classification, was measured using positive predictive value, negative predictive value, sensitivity, F1 score, and accuracy (otherwise termed Youden Index). RESULTS: A gold standard dataset of 6672 free-text clinical documents was manually annotated by human coders. Of these documents, 66.00% (4470/6672) were then used to train the SQL and MSIT approaches and 34.00% (2202/6672) were used for testing the approaches. To develop the MSIT, an iterative 2-stage approach was undertaken. In the first stage, an SQL method was developed to identify veterans using a keyword rule-based approach. This approach obtained an accuracy of 0.93 in correctly predicting civilians and veterans, a positive predictive value of 0.81, a sensitivity of 0.75, and a negative predictive value of 0.95. This method informed the second stage, which was the development of the MSIT using machine learning, which, when tested, obtained an accuracy of 0.97, a positive predictive value of 0.90, a sensitivity of 0.91, and a negative predictive value of 0.98. CONCLUSIONS: The MSIT has the potential to be used in identifying veterans in the United Kingdom from free-text clinical documents, providing new and unique insights into the health and well-being of this population and their use of mental health care services.

Modeling Stem Water Potential by Separating the Effects of Soil Water Availability and Climatic Conditions on Water Status in Grapevine (Vitis vinifera L.).

Measuring seasonal plant water status is critical in choosing appropriate management strategies to ensure yields and quality of agricultural products, particularly in a context of climate change. Water status of grapevines is known to be a key factor for yield, grape composition, and wine quality. Predawn leaf water potential (PLWP) and stem water potential (SWP) proved to be simple and precise indicators for assessing grapevine water status and subsequent same-day spatial comparisons. A drawback of SWP is that it does not allow for temporal comparisons, because the measured value is impacted both by soil water availability and climatic conditions on the day of measurement. The objectives of this study are i) to provide a model that separates the effect of soil water content from the effect of climatic conditions on the SWP value and ii) to standardize the SWP value to a value under predefined reference climatic conditions in order to compare SWP values collected under different climatic conditions. SWP and PLWP were temporally assessed on three soil types in Saint-Émilion (Bordeaux, France) in 2015 and on five soil types in Margaux (Bordeaux, France) in 2018 using a pressure chamber. SWP measurements on two consecutive days with contrasting climatic conditions allowed to assess the impact of these conditions on SWP values. A large portion of the variability in SWP values was explained by PLWP. Model selection further showed that the addition of maximum air temperature and seasonality explained a significant amount of the remaining variability in SWP values. SWP values could be successfully standardized to a theoretical value under reference climatic conditions, which allows for temporal comparisons of SWP values. A plant-based measurement, such as the water potential, can be considered as the most straightforward indicator of plant water status as it integrates the effects of soil, plant, and atmospheric conditions. More precise interpretation of SWP values provides winegrowers with a tool to more adequately implement short- and long-term management strategies to adapt to drought in order to ensure yield and grape quality.

Identifying Veterans Using Electronic Health Records in the United Kingdom: A Feasibility Study.

There is a lack of quantitative evidence concerning UK (United Kingdom) Armed Forces (AF) veterans who access secondary mental health care services-specialist care often delivered in high intensity therapeutic clinics or hospitals-for their mental health difficulties. The current study aimed to investigate the utility and feasibility of identifying veterans accessing secondary mental health care services using National Health Service (NHS) electronic health records (EHRs) in the UK. Veterans were manually identified using the Clinical Record Interactive Search (CRIS) system-a database holding secondary mental health care EHRs for an NHS Trust in the UK. We systematically and manually searched CRIS for veterans, by applying a military-related key word search strategy to the free-text clinical notes completed by clinicians. Relevant data on veterans' socio-demographic characteristics, mental disorder diagnoses and treatment pathways through care were extracted for analysis. This study showed that it is feasible, although time consuming, to identify veterans through CRIS. Using the military-related key word search strategy identified 1600 potential veteran records. Following manual review, 693 (43.3%) of these records were verified as "probable" veterans and used for analysis. They had a median age of 74 years (interquartile range (IQR): 53-86); the majority were male (90.8%) and lived alone (38.0%). The most common mental diagnoses overall were depressive disorders (22.9%), followed by alcohol use disorders (10.5%). Differences in care pathways were observed between pre and post national service (NS) era veterans. This feasibility study represents a first step in showing that it is possible to identify veterans through free-text clinical notes. It is also the first to compare veterans from pre and post NS era.

Do serving and ex-serving personnel of the UK armed forces seek help for perceived stress, emotional or mental health problems?

Background: UK armed forces personnel are at risk of occupational psychological injury; they are often reluctant to seek help for such problems. Objective: We aimed to examine and describe sources of support, prevalence and associates of help-seeking among UK serving and ex-serving personnel. Method: A total of 1450 participants who self-reported a stress, emotional or mental health problem in the past 3 years were sampled from a health and wellbeing study and subsequently completed a telephone interview comprising measures of mental disorder symptoms, alcohol misuse and help-seeking behaviour. Results: Seven per cent of participants had not sought any help, 55% had accessed medical sources of support (general practitioner or mental health specialist), 46% had received formal non-medical (welfare) support and 86% had used informal support. Gender, age, perceived health, functional impairment, social support, deployment, alcohol and comorbidity impacted upon the choice of help source. Conclusions: This study found that the majority of those with perceived mental health problems sought some form of help, with over half using formal medical sources of support.

Antecedentes: El personal de las Fuerzas Armadas del Reino Unido está en riesgo de sufrir alteraciones psicológicas ocupacionales; a menudo son reacios a buscar ayuda para tales problemas. Objetivo: El objetivo fue examinar y describir las fuentes de apoyo, la prevalencia y los asociados de búsqueda de ayuda entre el personal de servicio y ex personal de servicio del Reino Unido. Método: En un estudio de salud y bienestar se tomaron muestras de 1.450 participantes que informaron sobre un problema de estrés, de salud mental o emocional en los últimos tres años y posteriormente completaron una entrevista telefónica que incluía medidas de síntomas de trastornos mentales, abuso de alcohol y conductas de búsqueda de ayuda. Resultados: El 7% de los participantes no había buscado ninguna ayuda. El 55% accedió a fuentes médicas de apoyo (médico general o especialista en salud mental), el 46% recibió apoyo formal no médico (servicio social) y el 86% utilizó apoyo informal. El sexo, la edad, la salud percibida, el deterioro funcional, el apoyo social, el despliegue, el alcohol y la comorbilidad se ven afectados por la elección de la fuente de ayuda. Conclusiones: Este estudio encontró que la mayoría de las personas con problemas de salud mental percibidos buscaron algún tipo de ayuda, y más de la mitad usaron fuentes médicas formales de apoyo.

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.

Impact of paternal deployment to the conflicts in Iraq and Afghanistan and paternal post-traumatic stress disorder on the children of military fathers.

BACKGROUND: Little is known about the social and emotional well-being of children whose fathers have been deployed to the conflicts in Iraq/Afghanistan or who have post-traumatic stress disorder (PTSD).AimsTo examine the emotional and behavioural well-being of children whose fathers are or have been in the UK armed forces, in particular the effects of paternal deployment to the conflicts in Iraq or Afghanistan and paternal PTSD. METHOD: Fathers who had taken part in a large tri-service cohort and had children aged 3-16 years were asked about the emotional and behavioural well-being of their child(ren) and assessed for symptoms of PTSD via online questionnaires and telephone interview. RESULTS: In total, 621 (67%) fathers participated, providing data on 1044 children. Paternal deployment to Iraq or Afghanistan was not associated with childhood emotional and behavioural difficulties. Paternal probable PTSD were associated with child hyperactivity. This finding was limited to boys and those under 11 years of age. CONCLUSIONS: This study showed that adverse childhood emotional and behavioural well-being was not associated with paternal deployment but was associated with paternal probable PTSD.Declaration of interestN.T.F. is a trustee of the Warrior Programme, a charity supporting ex-service personnel and their families. She is also a member of the Independent Group Advising on the Release of Data (IGARD). S.W. is a trustee of Combat Stress, a charity supporting ex-service personnel and their families, and President of the Royal Society of Medicine. S.W. is partially funded by 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 (PHE), in collaboration with the University of East Anglia and Newcastle University.

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).

A genome-wide association study identifies susceptibility loci for Wilms tumor.

Wilms tumor is the most common renal malignancy of childhood. To identify common variants that confer susceptibility to Wilms tumor, we conducted a genome-wide association study in 757 individuals with Wilms tumor (cases) and 1,879 controls. We evaluated ten SNPs in regions significantly associated at P < 5 × 10(-5) in two independent replication series from the UK (769 cases and 2,814 controls) and the United States (719 cases and 1,037 controls). We identified clear significant associations at 2p24 (rs3755132, P = 1.03 × 10(-14); rs807624, P = 1.32 × 10(-14)) and 11q14 (rs790356, P = 4.25 × 10(-15)). Both regions contain genes that are plausibly related to Wilms tumorigenesis. We also identified candidate association signals at 5q14, 22q12 and Xp22.

Gene-gene interactions in breast cancer susceptibility.

There have been few definitive examples of gene-gene interactions in humans. Through mutational analyses in 7325 individuals, we report four interactions (defined as departures from a multiplicative model) between mutations in the breast cancer susceptibility genes ATM and CHEK2 with BRCA1 and BRCA2 (case-only interaction between ATM and BRCA1/BRCA2 combined, P = 5.9 × 10(-4); ATM and BRCA1, P= 0.01; ATM and BRCA2, P= 0.02; CHEK2 and BRCA1/BRCA2 combined, P = 2.1 × 10(-4); CHEK2 and BRCA1, P= 0.01; CHEK2 and BRCA2, P= 0.01). The interactions are such that the resultant risk of breast cancer is lower than the multiplicative product of the constituent risks, and plausibly reflect the functional relationships of the encoded proteins in DNA repair. These findings have important implications for models of disease predisposition and clinical translation.

Mutation and association analysis of GEN1 in breast cancer susceptibility.

GEN1 was recently identified as a key Holliday junction resolvase involved in homologous recombination. Somatic truncating GEN1 mutations have been reported in two breast cancers. Together these data led to the proposition that GEN1 is a breast cancer predisposition gene. In this article we have formally investigated this hypothesis. We performed full-gene mutational analysis of GEN1 in 176 BRCA1/2-negative familial breast cancer samples and 159 controls. We genotyped six SNPs tagging the 30 common variants in the transcribed region of GEN1 in 3,750 breast cancer cases and 4,907 controls. Mutation analysis revealed one truncating variant, c.2515_2519delAAGTT, which was present in 4% of cases and 4% of controls. We identified control individuals homozygous for the deletion, demonstrating that the last 69 amino acids of GEN1 are dispensable for its function. We identified 17 other variants, but their frequency did not significantly differ between cases and controls. Analysis of 3,750 breast cancer cases and 4,907 controls demonstrated no evidence of significant association with breast cancer for six SNPs tagging the 30 common GEN1 variants. These data indicate that although it also plays a key role in double-strand DNA break repair, GEN1 does not make an appreciable contribution to breast cancer susceptibility by acting as a high- or intermediate-penetrance breast cancer predisposition gene like BRCA1, BRCA2, CHEK2, ATM, BRIP1 and PALB2 and that common GEN1 variants do not act as low-penetrance susceptibility alleles analogous to SNPs in FGFR2. Furthermore, our analyses demonstrate the importance of undertaking appropriate genetic investigations, typically full gene screening in cases and controls together with large-scale case-control association analyses, to evaluate the contribution of genes to cancer susceptibility.

Variants near DMRT1, TERT and ATF7IP are associated with testicular germ cell cancer.

We conducted a genome-wide association study for testicular germ cell tumor, genotyping 298,782 SNPs in 979 affected individuals and 4,947 controls from the UK and replicating associations in a further 664 cases and 3,456 controls. We identified three new susceptibility loci, two of which include genes that are involved in telomere regulation. We identified two independent signals within the TERT-CLPTM1L locus on chromosome 5, which has previously been associated with multiple other cancers (rs4635969, OR=1.54, P=1.14x10(-23); rs2736100, OR=1.33, P=7.55x10(-15)). We also identified a locus on chromosome 12 (rs2900333, OR=1.27, P=6.16x10(-10)) that contains ATF7IP, a regulator of TERT expression. Finally, we identified a locus on chromosome 9 (rs755383, OR=1.37, P=1.12x10(-23)), containing the sex determination gene DMRT1, which has been linked to teratoma susceptibility in mice.

Genome-wide association study identifies five new breast cancer susceptibility loci.

Breast cancer is the most common cancer in women in developed countries. To identify common breast cancer susceptibility alleles, we conducted a genome-wide association study in which 582,886 SNPs were genotyped in 3,659 cases with a family history of the disease and 4,897 controls. Promising associations were evaluated in a second stage, comprising 12,576 cases and 12,223 controls. We identified five new susceptibility loci, on chromosomes 9, 10 and 11 (P = 4.6 x 10(-7) to P = 3.2 x 10(-15)). We also identified SNPs in the 6q25.1 (rs3757318, P = 2.9 x 10(-6)), 8q24 (rs1562430, P = 5.8 x 10(-7)) and LSP1 (rs909116, P = 7.3 x 10(-7)) regions that showed more significant association with risk than those reported previously. Previously identified breast cancer susceptibility loci were also found to show larger effect sizes in this study of familial breast cancer cases than in previous population-based studies, consistent with polygenic susceptibility to the disease.